1534

diagnose gastric cancer at a curable stage if dyspeptic patients areinvestigated early.A trial of symptomatic therapy is of no value in identifying which

dyspeptic patients have curable gastric cancer. In our study all of theearly gastric cancers and 3 of the stage II cancers had complete reliefof symptoms with antacids or H, antagonists. Where treatment wasstopped before surgery all remained symptom-free. ’

Discriminant analysis has shown symptoms to be of no value inidentifying the operable cancers. The pattern of symptoms given byHeatley and Rathbone as an indication for prompt investigationwere those which identified the advanced and inoperable cases.There was no pattern of symptoms or other risk factors which couldbe used to reduce significantly the number of patients investigatedand still identify all the early and operable cases.

Clinical impression is indeed an inaccurate method of diagnosingdyspeptic patients. The accuracy of the diagnosis offered by thegeneral practitioners and the hospital team exceeded 50% in onlyone group, those with peptic ulceration diagnosed by the hospitalteam. The accuracy of diagnosis in those with operable gastriccancer was less than 30%.We feel that it is not sufficient to treat dyspeptic patients over the

age of 40 symptomatically. If mortality from gastric cancer is to bereduced early diagnosis is essential. We have shown that earlyinvestigation in this group can achieve this objective. The provisionof a diagnosis in those with benign disease allows more rationaltreatment and reassures the patient. In some groups there is nodilemma. Dyspepsia in the over-40s requires investigation andendoscopy is the first investigation of choice.

Queen Elizabeth Hospital,Birmingham B15 2TH

M. T. HALLISSEY

J. W. L. FIELDINGW. H. ALLUMD. J. ELLIS

1. Evans DMD, Craven JL, Murphy F, Cleary BK. Comparison of early gastric cancerm Britain and Japan. Gut 1978; 19: 1-9.

2. Green PHR, O’Toole KM, Weinberg LM, Goldfarb JP. Early gastric cancer.Gastroenterology 1981; 81: 247-56.

3. Kawashima S. Early gastric cancer in Japan. Scand J Gastroenterol 1966; 1: 248-524. Kaibara N, Kawaguchi H, Nishido H, Kimura O, Okamoto T, Kuga S. Significance

of mass survey for gastric cancer from the standpoint of surgery. Am J Surg 1981;142: 543-45.

5. Hisamichi S, Nozaki K, Kitagawa H, et al. Evaluation of mass screening programmefor stomach cancer. Tohoku J Exp Med 1976, 118 (suppl). 69-77.

6. Fielding JWL, Roginski C, Ellis DJ, et al. Clinicopathological staging of gastric cancer.Br J Surg 1984; 71: 677-80.

Diagnosis?

(Concluded from p 1514)

An 81-year-old Polish refugee from the 1939-45 war,though he had lived in Manchester for 40 years, had a poorcommand of English. He was referred to the psychogeriatricdepartment in September, 1986, in an acute confusionalstate. Assessment and treatment were difficult becausecommunication was slow. The cause of his confusion was achest infection, which responded to treatment with anantibiotic. His mental state returned to normal. He was

discharged to the day hospital, where he was found to havethe strange rash. He was otherwise well. He explained thathe had experienced some mild chest pain and that he hadtreated it with the traditional treatment, cupping. Hisdaughter had assisted him. He told us that cupping wascommon when he was a child; members of his family hadreadily resorted to cupping to relieve painful conditions. MrS was a health conscious man who had persisted in usingtreatments prescribed many years ago. For instance, heregularly rubbed his feet with acetylsalicylic acid, whichhad been prescribed for frostbite almost 50 years ago.The procedures used to perform the treatment known as

cupping are recorded by Samuel Bayfield in A Treatise onPractical Cupping, published in 1823.1 He described twomain types of cupping, wet and dry. Our patient had carriedout dry cupping, using one of the methods in Bayfield. Heheated a glass in water and then held it over a flame to heatthe air inside. The mouth of the glass was immediatelyapplied to the skin near the affected area. The cooling of theair within the glass caused a partial vacuum which resultedin the skin being drawn into the cupping glass, the glassadhering to the skin. This process produced some relief ofsymptoms. Bayfield described a variation whereby a piece oflint was burnt inside the glass while it adhered to the skin.Wet cupping involved incising the skin, using an instrumentcalled a scarificator, so that blood was drawn into the glass.Bayfield recommended the treatment as "a powerful meansof alleviating many painful diseases". He encouraged themedical practitioners of his day to use cupping,commenting, "the neglect of it is surely an outrage uponcommon humanity, and casts a stigma upon the healingart...".

The practice has a long history which is traced in ATreatise on the Art of Cupping by Thomas Mapleson ( 1813).zThe author was cupper to His Royal Highness the PrinceRegent and to Westminster Hospital and the St PancrasParochial Infirmary. Mapleson quoted Hippocrates on theuse of cupping, and described its effect upon painfuldisorders such as pleurisy and headaches as well as throatinfections and its use in delerium, insanity, and dejection ofthe spirits. He believed that the earliest practitioners wereprobably the Egyptians and he reported that cupping wasstill popular in Egypt even when other treatments were moreappropriate: "They are either unacquainted with the use ofleeches, or have a prejudice against them..." In Mapleson’stime, cupping was often performed by unskilled

practitioners. He wrote disapprovingly of advertisements,offering cupping at the bath houses, which appeared in TheTatler and The Spectator. During the 19th century Britishmedicine abandoned the practice although it was stilldescribed in papers from eastern Europe as late as 1940.3From the beginning of this century, cupping has beendescribed as of historical interest only in British

publications, although doctors working overseas havementioned its beneficial effects. In 1915, Doudney reportedthat Nigerians used cupping to good effect in relievingmuscular pains.4 In 1923, Gubb described the practice ofdry and wet cupping in Tunisia.5 He wrote "I have beenstruck by ... [its] efficacy in relieving inflammatory andcongestive states".

Cupping is now of historical interest only, although itsurvives in modified form. It may be the origin of othertypes of vacuum instruments, such as the ventouse

apparatus in obstetrics. Bayfield described a device usingsuction which might be used in "abstracting milk from theimperfectly developed nipple of young mothers". Althoughcupping is "a long discontinued practice", we shouldremember that it lives on in the memories of some older

patients as an effective and simple remedy. Unusual signs orsymptoms may be due not to mental illness but to traditionaltreatments.

REFERENCES

1. Bayfield S A Treatise on Practical Cupping. London 18232. Mapleson T. A Treatise on the Art of Cupping. London: 18133. Travner L. Lyecu Vjes 1940; 62: 600-034. Doudney L. Br Med J 1915; i: 5025. Gubb AS Br Med J 1923; i. 639.6. Dickenson V. Proc Roy Soc Med 1916-17; 10: 90-93.