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History of cupping (Hijama): a narrative review of literature

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● Review
History of cupping (Hijama): a narrative review of
literature
Naseem Akhtar Qureshi, Gazzaffi Ibrahim Ali, Tamer Shaban Abushanab, Ahmed Tawfik El-Olemy,
Meshari Saleh Alqaed, Ibrahim S. El-Subai, Abdullah M.N. Al-Bedah
National Center of Complementary and Alternative Medicine, Ministry of Health, Riyadh 11662, Saudi Arabia

ABSTRACT
Cupping (Hijama in Arabic) is an ancient, holistic method for the treatment of a variety of diseases. Though the
exact origin of cupping therapy is a matter of controversy, its use has been documented in early Egyptian and
Chinese medical practices. Diverse human civilizations have contributed to the historical development and
continuation of cupping therapy. This narrative review describes the history of cupping, historical definitions,
cupping instruments and uses of cupping therapy. Electronic searches of relevant databases (PubMed,
Google Scholar and OvidSP) were conducted using keywords and Boolean operators. Manual searches
and references of published articles and books were also conducted. A number of articles (N = 625) were
retained for extensive review, and finally 83 articles were included in this paper. The historical descriptions
of cupping therapy were found in ancient human civilizations of the Eastern and Western world. There were
inconsistent data concerning the origin of cupping, definitions, instruments, procedures, definite advancements
and research in Hijama over centuries. Cupping therapy fell out of favor in 17th and mid-18th centuries but
recovered popularity in modern medicine. Currently, cupping therapy is used for health promotion, prophylaxis
and treatment of a variety of diseases around the world. Cupping therapy with a good safety profile has a
checkered history and is a well-recognized traditional method for managing medical conditions. Currently, the
scope of cupping therapy is expanding, and a growing body of research is providing additional evidence-based
data for the further advancement of cupping therapy in the treatment of a variety of diseases.
Keywords: cupping; history; review
Citation: Qureshi NA, Ali GI, Abushanab TS, El-Olemy AT, Alqaed MS, El-Subai IS, Al-Bedah AMN. History of
cupping (Hijama): a narrative review of literature. J Integr Med. 2017; 15(3): 172–181.

1 Introduction
Cupping therapy (CT), Hijama in Arabic, has been
practiced in many countries of the world since ancient times.
CT is one of the oldest traditional procedures in holistic folk
therapy around the world.[1,2] Although the beginnings of
CT are shrouded in controversies, the practice has provided
assistance in curing medical and surgical ailments, and was
an important component of the effective therapeutic methods
of ancient times. Traditional CT methodologies have been
passed from generation to generation by its practitioners.[3–5]
Historically, the search for medical care has been a powerful
motivation that has driven people to migrate and travel across
international boundaries.[6,7]
This narrative review describes the history of cupping,
definitions, cupping instruments and the traditions of cupping
among various civilizations of the world. The importance
of this review is that it will fill up the knowledge gap in
the history of cupping. It also provides a reliable source for
historical knowledge of several aspects of CT, which can be
used for training of traditional and modern practitioners and
to help researchers around the world.

http://dx.doi.org/10.1016/S2095-4964(17)60339-X
Received December 20, 2016; accepted February 24, 2017.
Correspondence: Naseem Akhtar Qureshi, MD, PhD; E-mail: qureshinaseem@live.com

May 2017, Vol. 15, No. 3 172 Journal of Integrative Medicine


2 Methods
2.1 Search strategy
The relevant literature published in English (prior
to December 2016) was searched in PubMed, Google
Scholar and OvidSP databases. The Boolean operators
and keywords used in multiple electronic searches were
“history AND wet and dry cupping,” “history AND
Hijama,” “history AND cupping instruments,” “cupping
definitions OR cupping in ancient cultures” and “different
cupping methods AND cupping safety.” The search
strategy and the keywords were modified as appropriate
according to the searched database. In addition, references
included in full text articles, some history of traditional
medicine books and treatises on history of CT/Hijama
were reviewed for inclusion.
2.2 Search results
More than 625 articles were retrieved and reviewed
by two independent researchers. Our focus was on full
articles describing cupping history. However, we also
reviewed articles that gave brief descriptions of the
history of cupping. These brief sketches were reviewed
critically and their important contents were incorporated
in this paper. The additional inclusion criteria were access
PubMed Google Scholar
Identification
Total aticles retrieved (N = 625)
Articles screend on basis of title
and abstracts
Screening
Article left (n = 112)
Eligibility
Other exclusion and
inclusion criteria applied
Included
Retained articles
（70+13 = 83）
Figure 1 The flowchart of selection of articles
Journal of Integrative Medicine 173
www.jcimjournal.com/jim
to full articles, papers containing CT history information
and all types of studies such as systematic reviews and
meta-analysis, randomized clinical trials, observational
studies, case series and single reports. After removal of
duplications (n = 241), no cupping history at all (n = 164),
no abstract (n = 33), non-English articles (n = 17), incomplete
papers (n = 37) and full articles not accessible (n = 21), only
112 papers were left for further review. Furthermore, 42
articles were excluded because of duplications of cupping
history information and containing irrelevant information.
Finally, both reviewers agreed to include 70 published
studies, including 12 historical traditional books on
cupping, in the present narrative review. Thirteen further
references suggested by reviewers were added to this
paper. Now the total number of included studies is 83
(Figure 1).
3 History of CT
3.1 Historical definitions of cupping
Hijama, or cupping, has been defined differently in
traditional and complementary medicine practice from
various civilizations; however, a common element
among its uses is the extraction of toxic substances
OvidSP
Without abstracts = 33; duplication = 24;
unrelated papers = 164; no full articles = 37;
published in non-English literature = 17;
full articles not accessible = 21
Excluded (n = 42)
Duplications of cupping history information
and containing irrelevant information
Ariticles suggested by
reviewers (n = 13)
May 2017, Vol. 15, No. 3
 www.jcimjournal.com/jim
(detoxification) from the body by creating negative
pressure in the cup. [4,5] Taber’s Cyclopedic Medical
Dictionary reveals that the application of a glass vessel
to the skin, from which air can be exhausted by heat or
by a special suction apparatus, is known as cupping.[8] In
the English language, Hijama is called cupping. Several
scholars of Unani medicine have defined cupping in their
own words. Razi [9] stated that cupping was a process
in which blood (toxic) from superficial small vessels
located in muscles is released. Sheikho[10] described the
process of making an incision, known as Pachhna (prick
or puncture), in CT. Accordingly, the noxious matter
accumulated close to the skin was effectively removed.
Jurjani[11] clarified that cupping was a process by which
superficial bleeding was initiated from the smaller vessels
or their branches, situated within the muscles, to decrease
congestion. Furthermore, Jurjani [11] believed that this
process did not produce weakness in the vital organs.
Baghdadi[12] defined cupping as a process which helped
in blood removal from the small vessels of the skin and
muscles, reducing congestion in the area where cups were
applied. Kabiruddin[13] added that cupping at the lower
extremities, especially at ankle joints, was similar to
venesection, as he believed that normal blood and noxious
matter moved downward. CT further attracted these
materials and, therefore, the amount of blood released
during wet cupping at ankle joints was higher than that
in venesection. The cupping therapist should thus be
careful about excessive bleeding when cups are applied
at ankle joints. Notably, bloodletting by phlebotomy and
venesection is completely different from cupping. In CT,
no veins are cut, unlike phlebotomy or venesection.[13,14]
Typically phlebotomy (or modern bloodletting) refers to
the action of drawing blood from a vein for laboratory
tests (small amount), or blood donation (500 mL), whereas
currently venesection refers to a clinical procedure.
Bloodletting with a therapeutic intent is the withdrawal of
toxic and harmful blood from a patient to cure or prevent
any disease and illness as was considered in ancient
system of medicine. Accordingly, blood and other bodily
fluids were conceptualized as “4 humors” (blood, phlegm,
black bile and yellow bile) and an imbalance of any of
these could lead to illness. Therefore, they had to remain
in balance to maintain the healthy life.[14,15] According to
Sina,[16] cupping was the process of making an incision
used to release toxic matter accumulated close to the skin.
Traditionally, CT has been practiced in one form or
another in most cultures of the world for centuries. The
Arabic name for CT is Al-Hijama, which means literally
“to reduce in size,” and more generally “to return the body
back to its natural state.” In other words, Hijama refers to
balancing the body humors. There is also a verb “Ahjama”
which means “to withdraw or retreat from attack.” [10]
May 2017, Vol. 15, No. 3 174
Overall, there are several overlapping definitions of CT
and the word “Hijama” in Arabic has similar connotations
of returning the body to its natural state.
3.2 Sources of cupping
The earliest recorded references to CT use are found
in the Ebers Papyrus, written by Ancient Egyptians in
Hieroglyphics, about 1550 B.C.[17] Ge Hong[18] (281–341
A.D.), a well-known Taoist alchemist and herbalist from
China is also known to have written on CT. CT use in
Egypt dates to 3500 B.C. and its practice is documented
in hieroglyphic writing.[19] In ancient Greece, Hippocrates
advocated CT for many ailments.[20] In the early 1900s,
Sir Arthur Keith (1866–1955 B.C.) mentioned that CT
was performed with successful outcomes. [7] In China,
CT forms one of the cornerstones of traditional Chinese
medicine (TCM). CT is very popular in Chinese public
hospitals employing TCM, and extensive research on
CT has been carried out in China.[21] The evidence-based
value of CT has been documented through hundreds of
years of research, clinical experience of practitioners
and subjective experience of users worldwide. In ancient
Macedonia (3300 B.C.), CT was to treat diseases and
health disorders.[22] In modern medical sciences, CT is
used in a variety of human diseases.[5,7,23]
Interestingly, women practitioners have played a special
role in perpetuating the use of traditional therapies,
including CT, since ancient times. As a family tradition,
women practitioners not only successfully practiced CT for
healing purposes but also passed their skills and knowledge
from generation to generation.[7,24] Some studies found that
women played a major role as folk healers in most cultures
of the world.[7,24] Evidently, CT was usually performed by
women throughout Europe, Africa, Asia, Middle East and
other continents.[7,24] Unfortunately, by the 13th century, all
universities excluded women from their classes. Despite
a lack of importance given to folk medicine education
during this period, women continued to provide various
healing remedies including CT to patients.[7,24] Archived
documents and books recovered from ancient cultures
especially in Egyptian, Chinese, Greek and Middle East
are the main sources of information of the early history of
cupping.
Similar ancient civilizations were also the sources of a
variety of instruments and tools used in CT practice, such
as hollowed animal horns (Figure 2A), bones, bamboo
(Figure 2B), nuts, seashells and gourds. These devices were
used for suctioning harmful humors from ill people.[1,5]
Historically, the most common diseases managed by CT
have been pains, bites, pustules, headache, infections and
skin lesions.[1,3,4,23] Many cupping instruments and tools,
including animal horns and metal cups, used in early
practices were slowly replaced by cups of different sizes,
shapes and materials, such as glass, plastic, rubber and
Journal of Integrative Medicine

silicone.[1,23] Similarly, electric suction machines are new
innovations that may replace manual suction instruments
and fire as a method of decreasing the pressure inside of
CT cups. Furthermore, instruments used for scarification,
or bloodletting, such as traditional razors, have also been
replaced by sterile surgical blades, plum blossom needles
and the auto lancet.
A B
Figure 2 The cupping instruments of horn (A) and bamboo (B)
3.3 Ancient Egyptians and CT
CT is an ancient medical art practiced and sustained by
various human civilizations. According to Hasan et al.,[7]
CT was practiced in Egypt more than 5 500 years ago, and
was symbolized in ancient hieroglyphics. Interestingly,
ancient Egyptians were reported to practice CT earlier
than all other civilizations.[17,25] CT is considered to be
one of the oldest medical therapies in ancient Egypt.
Drawing found on famous Egyptian papyrus and in
ancient Egyptian temples demonstrated that Egyptians
were highly advanced in the treatment of various diseases
through several treatment methods. Drawings of cupping
instruments were found at the Temple of KomOmbo,
Luxor.[25] The Ebers Papyrus, an ancient medical textbook
(1550 B.C.), discussed the application of cups for
fever, pain, vertigo, dysmenorrhea, lack of appetite and
constipation. This book also highlighted how to accelerate
the “healing crisis” of diseases using CT.[25] The ancient
Egyptians introduced CT to the Greeks and subsequently
CT spread to other European countries and eventually to
the Americans.
3.4 Chinese culture and CT
Traditional Chinese medical practice, which has a
history of several thousands of years, includes its own
form of CT.[26] The earliest discovered record of cupping
in China was in the Wu Shi Er Bing Fang, an ancient book
written on silk. This book was discovered in an ancient
tomb of the Han Dynasty in 1973.[27] Early written records
in China (28 A.D.) strongly support the use of CT and
acupuncture. It stated that “more than half of the illnesses
will be cured by acupuncture and cupping.”[7,13,28–30]
Zhao Xue-min, a Chinese doctor in the Qing Dynasty
wrote a book entitled Bencao Gangmu Shiyi (Supplements
to Compendium of Materia Medica) about 200 years ago,
Journal of Integrative Medicine
www.jcimjournal.com/jim
describing details of the history and origin of different
kinds of cupping, cup shapes, their functions and clinical
uses in the treatment of diseases.[31,32] Cupping has also been
known as “Jiao Fa” which means the horn technique.[33,34]
In this method, hollowed horns were used in CT practice
(Figure 2A). Many other names were used to describe
cupping techniques, including “sucking method,” “fire
cupping” and “boiling bamboo cylinder” in early Chinese
practice.[35] In fact, Chinese practitioners have continuously
contributed to the advancement of CT methods and their
efficacy against various diseases through research.[31,32]
3.5 Arabic medicine and CT
The practice of CT in Arabic medicine began around
3500 B.C. and Assyrians were the first recorded Arab
practitioners. In the Arabic medical context, CT is a
technique that returns an ill state to its original state.[10] CT
was used in the treatment of hypertension, polycythemia,
headache and migraine and drug intoxication among
Arabian communities. [7,22,36,37] Interestingly, Arabic
practitioners diagnosed polycythemia based on excessive
pink color of the skin. [36] Venesection, a form of
phlebotomy used in the treatment of polycythemia, differs
from cupping. In this process, some blood is drawn out
from veins and is replaced by saline infusion.[37]
3.6 Unani medicine and CT
Unani (means “Greek” in Arabic) medicine is an
Islamic healing philosophy. It mainly focuses on four
major elements of ancient Greek medicine, which include
earth, fire, water, air and four corresponding humors
including phlegm (balgham), blood (dam), yellow bile
(safra) and black bile (sauda). A balance in the humors
in the body indicates good health while a disturbance
in their equilibrium results in disease.[14,15] According to
Unani medicine, Hijama is an Arabic word which has
two different meanings. Hijama refers to the process of
scalp hair removal (Hijamat) or the application of cups
(Seenghi).[13,28] Hijama has been practiced since ancient
times, and the Unani physicians were the first to use CT
in a systematic way.[13,28] More than 70% of the Indian
population lives in villages,[6] and traditional medicine
has historically been widely used in rural areas of
India. Nonetheless, no records of CT were found there.
Hippocrates (the father of modern medicine) described
both dry and wet cupping in his treatise Guide to Clinical
Treatment which has been widely employed for the cure
of a variety of medical conditions.[28] Galen, a prominent
Greek physician, surgeon and philosopher in the Roman
Empire was a known practitioner of CT.[13,27,28] CT was
also used in ancient Greece by Hippocratic medical
practitioners.[38,39] Herodotus, a Greek historian, wrote
that Egyptian physicians used both wet cupping and dry
cupping for a variety of diseases, including inflammatory
diseases, in 400 B.C.[20,27,34,40,41] Bayfield[42] wrote in 1839
175 May 2017, Vol. 15, No. 3
 www.jcimjournal.com/jim
about Hippocrates, who advised practitioners to use cups
of small diameter, spherical shape and light weight.[43]
3.7 Prophetic medicine and CT
Prophetic medicine is a term given to the knowledge
gained from teachings, advice and sayings (hadiths) of
the prophet Muhammad (570 C.E.), related to health
and the treatment of diseases.[44] Prophetic medicine has
both preventive and curative values, and addresses the
problems of body and soul. Loukas et al.[45] stated that
information gathered from the Qur’an (the holy book of
Islam) and hadiths may be a significant source of home
remedies due to their surprising concordance with modern
therapies. [45,46] The Prophet Muhammad recommended
many forms of therapies, including CT and honey. He also
recommended cautery as a last choice of treatment.[45,46]
Prophetic medicine also recommended a variety of herbs
and foods, such as Nigella sativa and dates,[47] as well as
applied therapy, such as hydrotherapy.[48]
Many Arabic companions of the Prophet have reported
his hadiths concerning CTs. In Sahih Bukhari, the
messenger said, “indeed the best of remedies you have
is cupping.”[29,44,46] The messenger said: “healing is to be
found in three things including use of honey, cupping and
cautery.”[44–46] Ibn al-Qayyim Jawzi believed that cupping
was considered as an effective medical practice.[29,30,49,50]
The author of the book entitled Al-Qanoon, Sina [51]
(980–1037 B.C.) said: “Cupping is neither preferred in
the beginning nor the end of the month. It is preferred
in the middle of the month when the toxic substances
accumulate.” Furthermore, Ibn Sina said that CT can treat
more than 30 different diseases. A different hadith states
that “the Prophet used to have cupping done on the 17th,
19th and 21st day of the lunar month.” For other important
hadiths of the Prophet concerning Hijama see this source.[52]
Overall, Islamic cupping practitioners (Islamic medicine)
have played a significant role in reviving and sustaining
CT across the Islamic countries.
3.8 European and American culture and CT
CT spread from ancient Egypt to the medical practices
of many European countries and the Americans. In the
UK, the practice of CT also dates back hundreds of years.
One of the leading medical journals The Lancet is named
after CT practice. A lancet is a piece of surgical equipment
that was traditionally used to release excess blood
through venesection and to prick boils.[4] European and
American physicians were widely using CT during the
19th century (1800s–1900s). Wet cupping was the most
used CT modality. In the early 20th century, the use of
CT significantly declined across the world. Revival of CT
began in the mid-20th century. In the 1950s, collaboration
between Chinese and Russian researchers confirmed the
clinical applications of CT in Chinese hospitals[7,28] and
by extension to other healthcare settings in both countries
May 2017, Vol. 15, No. 3 176
and possibly elsewhere in the world.
3.9 Historical and modern cupping instruments
The earliest cupping instruments were hollowed animal
horns with a small hole at the top through which the
therapist would suck out the air.[24] Subsequently, various
natural objects began to be used for cupping practice. For
example, natives along the west coast of North America,
in the vicinity of Vancouver Island, used shells. In Europe,
Asia, Africa and North America, animal horns were
fashioned into an effective cupping devices.[26] In North
America, the natives made cupping instruments by slicing
off the apex of a buffalo horn to making a hole.[27,31] The
base of the horn was then placed on a specific skin area
and the air was sucked out by mouth. After creating a
vacuum, the opening of the horn was closed off with a
piece of wax. In the Babylon-Assyrian Empire, CT was
also conducted with a buffalo horn. This information
was found inscribed on clay tablets, which may have
dated back to nearly 700 B.C.[28] Cupping and bleeding
instruments, such as various scalpels and cupping vessels,
were found at the Temple of Asclepius at Athens.[38] The
use of horns slowly gave way to bamboo glass and plastic
cups.[19,24,26,31]
Since the 17th century, different types of cups have
been used in CT around the world.[53] Medical equipment
manufacturers produce cupping sets from the middle part
of the 20th century. CT instruments and tools have been
further developed to include new glass cups, magnetic
cups, manual pumps and electrical suction devices. Now,
new cupping devices continue to be developed. Notably,
manual vacuum pumps perform the same function that
the traditional fire suction method did. The connecting
tube and valve allow the therapist to create and release
suction with precise control of pressure and ease of
movement. [28–30] Overall, this trend reflects continuing
innovative progress in CT procedures, cupping types,
instruments and classification.[5,17,23]
3.10 Historical uses of cupping
CT has been used therapeutically around the world for
thousands of years, dating back to the era of the ancient
Egyptian civilization. CT can be divided into dry cupping
and wet cupping. Dry CT used to be practiced more
commonly in the Far East, while wet CT was preferred
in the Middle East and Eastern Europe.[54,55] CT has been
used historically to treat many acute and chronic diseases,
including several painful conditions, nausea and vomiting,
urinary tract infections, disabilities, respiratory ailments
and rheumatic disorders.[3,4,22,23,33,39,54,56] Initially, CT was
used primarily for the treatment of diseases associated
with aches and pains; however, the clinical experience
over the past few centuries has applied these techniques
to the treatment of many chronic conditions, such as
musculoskeletal diseases, cardiovascular disorders, skin
Journal of Integrative Medicine

diseases, inflammatory disorders, neuropsychiatry problems
and metabolic disorders.[18,54] According to some research,
wet cupping may be used effectively in the treatment of a
variety of diseases, such as hypertension and carpal tunnel
syndrome.[7,28,54] A number of historical books mentioned
the use of wet and dry CT.[11,16,27,31,42] Herodotus (a Greek
historian, 400 B.C.) reported the use of CT for the treatment
of headaches, lack of appetite, indigestion, fainting, abscess
evacuation and narcolepsy.[4,20,22] In the early 2nd century,
Aretaeus used both wet and dry cupping to treat prolapse
of uterus, cholera and epilepsy. Galen was a great Greek
physician who used cupping methods and described various
types of cups such as horn, glass and brass cups.[27,57,58]
Scientist Celsus (a Greek philosopher and encyclopedist
best known for his medical writings) recommended cupping
for the treatment of abscesses and for extracting poisons
from bites made by men, apes, dogs, wild animals and
snakes.[27] Interestingly, Hippocrates recommended CT for
the management of musculoskeletal diseases of the back
and extremities, gynecological complaints, pharyngitis,
ear ailments, angina and lung diseases.[3,4,33,38,41] Similarly,
traditional ancient Egyptians, Chinese and Middle-
Eastern physicians used CT for a variety of ailments. In
Europe, CT was used for healing purposes by monastery
practitioners and folk healers up to the 19th century.[38,59–63]
3.11 Revival of cupping
CT was ignored for a long period from the mid-18th
until its revival in the mid-20th century.[47] The Prophet
Muhammad himself was treated with cupping and
recommended it.[58] In the 17th and mid-18th centuries,
cupping was used extensively across the world including
China, Egypt, Greece, the Middle East and Europe. By
the mid to late 1800s, the medical community strongly
criticized CT and, hence, CT lost its popularity. [22,32,63]
Consequently, the medical community of the Western
world lost interests in CT. [32,58] Nevertheless, CT was
globally revived after mid-20th century.
Cupping has regained popularity over the past six
decades, as people have realized that some traditional
practices have therapeutic values in some medical
conditions.[32,51,64] CT’s revival can be attributed to its
promotion by acupuncturists, cupping therapists, and
holistic healthcare practitioners around the world. New
and exciting CT types, such as cupping massage and
magnetic cupping, have enhanced its reputation and
popularity. Innovative training methods and safety tools
developed for cupping also helped in its restoration.[23,65,66]
One key element of the popularity of cupping is its great
ability to promote a state of pleasure and relaxation with
a good safety profile.[66] Currently, CT is most widely
used in China as part of TCM. Chinese hospitals have
recognized CT as a formal modality of treatment since
1950.[21] Furthermore, medical practitioners in China and
Journal of Integrative Medicine 177
www.jcimjournal.com/jim
Mongolia regularly practice CT for treating hypertension,
pain and infectious diseases.[7,21,67] CT is now practiced
in many countries of the Eastern and Western world.[27]
Some of the European countries changed their attitude
towards complementary medicine and decided to integrate
it within the conventional healthcare system. [61,68] In
the United States, there have been a gradual increase
in the use of CT and other types of complementary and
integrative remedies.[69] In a recent report from Harvard
Medical School about pediatric patients with chronic pain,
authors reported that cupping and acupuncture treatments
were pleasant and helpful for pain conditions.[70] Cupping
treatment is used to reduce musculoskeletal inflammation
and pain, and may consequently increase physical
performance during sport activity.[71] The value of CT as
a prophylactic method and its promotion of health and
energy was implied during the 2016 Olympic Games
held in Rio de Janeiro, Brazil, when an outstanding
swimmer used it prior to a swimming event and broke the
world record.[72] However, whether or not CT effectively
enhances athletes’ performance is still questionable and
needs further study. CT has a very long history, as shown
in the timeline in Figure 3. In addition, CT studies,
including randomized clinical trials,[39,60,61,73–75] systematic
reviews and overviews of systematic reviews, [21,28,76–79]
observational research and case studies,[7,23,54,62,63] add to
an increasing body of evidence-based data supporting the
effectiveness of CT in the treatment of various diseases
and recommend its continued practice and standardization
in the future. Although these studies supported the
effective use of CT against a plethora of diseases, it
is recommended to conduct rigorous and high-quality
studies to show further effectiveness of CT in various
medical conditions. An extensive review of current studies
on CT is beyond the scope of this historical review.
Figure 3 Cupping therapy timeline
4 Discussion
The history of CT is as old as the history of human
civilization. The first use of CT was recorded by ancient
Egyptians in the Ebers Papyrus. [1,17,28] Later on, the
Chinese practitioners used cupping to treat medical
conditions for several thousands of years. Cupping
is known by several names, as revealed in some
May 2017, Vol. 15, No. 3
 www.jcimjournal.com/jim
historical books written by ancient Chinese doctors and
historians.[26,27,31,35] Consequently, CT became one of the
key components of TCM, and was used historically in
the treatment of many conditions including human and
animal bites, infected wounds, high blood pressure, skin
diseases and other numerous diseases associated with or
without pain.[4,19,22,23,26,27,29–32,39] Other painful conditions,
such as some types of headaches and migraines may also
be treated with CT.[3–5,21,22,39,54] These diseases are known
to impose a large burden on public health around the
world.[54] However, further studies are needed to provide
strong evidence that CT is effective in medical conditions
associated with or without pain. Studies that estimate
the cost-effectiveness of CT in various diseases are also
needed.
Ancient Egyptians transferred cupping to Greek and
Roman cultures, where Hippocratic physicians and
Herodotus recommended the use of cupping for many
medical conditions, including gastrointestinal and brain
diseases.[19,25,38] Ancient Greek physicians passed the skills
of CT to Middle East societies.[28,55] Prophet Muhammad
was treated with CT and also recommended its use against
a variety of diseases such as eye, skin, brain and digestion
problems.[52,58] The Prophet said that the cure of diseases
could be found in honey, cupping and cautery; however,
the use of cautery was the last option, [30,49] mostly in
resistant diseases.[80] Notably, only hollowed animal horns
and bamboo cups were used in CT in Middle East cultures
for the effective management of multiple ailments.[13,16,19,26]
CT is known to have had periods of disfavor among
clinicians. CT was criticized and overlooked by its
opponents for many decades in the late 19th to early 20th
century.[47] Nonetheless, traditional practitioners continued
to use CT in some areas of the world.[5,10,44,52,58] With time,
definitions of CT evolved, its medical use was expanded,
cupping instruments were developed, medical research
was conducted, its contraindications were identified
and its mechanisms of action were suggested.[4,5,27,52,64,70]
Finally, CT is a promising therapy, as many studies are
providing evidence-based data in favor of its effectiveness
and safety.[21,32,66] CT is reported to have some side effects,
including scars, burn, abscess and infections, especially
when it is used by unqualified and untrained practitioners,
who fail to apply infection control measures.[66]
Many theories describing the therapeutic mechanisms of
CT, have been put forward over the centuries of its practice.
Shaman in primitive societies believed it to suck devil
and infirmity from the body.[40] Beliefs that CT extracts
toxic or poisonous substances (detoxification) in the blood
were promoted in ancient times and continue to be part
of our understanding of the technique.[4,5,27,64,70] Sucking
contaminated blood from the affected, inflamed area reduces
congestion, increases fresh blood supply and may speed
May 2017, Vol. 15, No. 3 178
up recovery. CT also corrects imbalance in the internal
bio-field through restoring the flow of Qi.[81] Its other
suggested mechanisms of action include boosting immunity
and promoting anti-inflammatory process through the
removal of oxidants and reduction of oxidative stress.[82] CT
applied to the inter-scapular area may help in discharging
waste materials, invigorating the body metabolism and
also regulating blood chemistry. [83] In summary, the
understanding of CT’s mechanisms of action has evolved
over the centuries of its practice,[4,5,22,27,31–35,64,70,75–81] and
its detailed description is not the focus of this historical
review paper.
This study has some limitations. Lack of specific
research in the field of CT history, fragments of
information, conflicting information and the lack of proper
documentation of traditional healing practices are the main
limitations. In addition, old archived sources of cupping
history were difficult to access. In these cases, we have
quoted them from other articles whose authors fortunately
read the whole articles. Publication and selection biases
are two other limitations of this paper. This is a narrative,
qualitative review of cupping history; the quantitative data
presentation in a tabulated form is beyond the scope of
this study. However, the timeline of cupping history and
its sequential map of different civilizations since ancient
time are shown in Figure 3 and Figure 4, respectively.
There are some strengths to this review. This historical
review of CT is based on scientific qualitative data
collected from a large number of reliable sources. Lastly,
this review has focused on all the ancient civilizations
(Figure 4) that have contributed to the continuing
development and continuation of CT around the world.
To conclude, Ancient Egyptians were the first to
practice CT in the Western world and then they spread
its practice to Greeks. Ancient Chinese, Greeks and
Middle-East civilizations practiced CT and contributed
Acient
Egyptians
European
and Ancient
American Chinese
culture
Cupping
therapy
Greek
Prophetic
medicine
Unani
medicine
Arabic
medicine
Figure 4 Ancient to modern civilizations and cupping therapy
Journal of Integrative Medicine

to its continuous development. Simultaneously, cupping
instruments and methods were improved and in each
civilization, cupping was used effectively against a
variety of ailments. Currently, the use of cupping is
increasing for health promotion and treatment of variety
of diseases across the world. CT has a good safety profile
but is reported to have some side effects when used by
untrained practitioners. There is a need for more research
on the mechanisms of action, efficacy and safety of CT to
provide evidence-based data and support in setting up CT
standards, guidelines and regulations.
5 Conflicts of interest
The authors declared no conflicts of interest in this
work.
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