JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

PRACTICAL GUIDE T0
CUPPING THERAPY
by Ilkay Chirali

T
he first time I came across cupping was when room, and then let them stay in the steam for ten to
I had a bad cold and my mother put some fifteen minutes in order to induce sweating. This
cups on my back. I could feel the edges of the was a useful approach since few people had Turk-
glass sinking deep into my flesh. As the bruises ish baths in their own homes. Almost every home
appeared, my mother took the cups off, only to in Cyprus has a set of cups in their cupboards. In
replace them with fresh ones! After cupping I was the old days olive oil wicks and ordinary drinking
rubbed with home made alcohol and made to stay glasses or empty marmalade jars were used for
in bed, covered with plenty of blankets in order to cupping. Nowadays properly designed thick edged
make me sweat. Sure enough, within half an hour cupping glasses are imported from France or the
the bed was soaked with sweat. As soon as the sweat- Far East. This very ancient Chinese medicine prac-
ing was over I was pushed into a hot tice was introduced to the Mediterra-
bath and then returned to bed.The nean region by the Ottoman Turks
next day I was able to play out- who originally came from
side with the other children Turkistan, now part of the
and my cold was history. People’s Republic of
This story is, perhaps China (Sinkiang Uighur
surprisingly, not one Autonomous Region
which took place in of the People’s Re-
China, but in my public of China,
native country of East Turkistan). As
Cyprus. I was the Ottomans
seven years old moved West, and
when I had my eventually into
first cupping ex- Europe, this tra-
perience, and in dition came with
the following them. Today
years, I remem- most of the Medi-
ber cupping was terranean cul-
the only method tures still use cup-
used in our home ping, especially
for treating cold the Turks, Greeks,
conditions such as Arabs, Southern
sneezing and runny Italians, Southern
nose with headache French and Spanish.
and stiff back due to While cupping was al-
working in the rain or ways a folk medicine in
wind, and was even used for these countries, it was used
bed wetting (In Turkish folk more scientifically in English
medicine, bed wetting is considered hospitals in the past. Frieda Sandwith
to be a symptom of weak back due to “catch- in “Surgeon Compassionate”3 describes the
ing cold on the back”, or due to some kind of shock). work of her great grandfather William Marsden
My grandmother, who was the only midwife in and the use of cupping in hospitals in the 1830’s to
the area, also used cupping quite extensively for treat contagious diseases. She refers to “paid
the treatment of many female complaints, such as cuppers” working in these hospitals. Unfortunately,
painful or irregular periods, cold in mother’s milk 1, as modern drugs were developed, cupping along
miscarriage due to weakness of the back 2 and many with other simple but effective methods, as well as
more general complaints. She would use different the traditional Apothecary, were excluded from
sized drinking glasses and marmalade jars for cup- general practice, being contemptuously regarded
ping. Her favourite method was to take her pa- as “old women’s remedies”. It is very ironic that
tients to a Turkish bath, apply the cups in the cold we, as alternative practitioners, have to prove to
today’s medical profession that cupping - and in-

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 JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991
deed many more previously practised therapies -
do work effectively and are as cost effective today
as they were then.
Which cups to use
Sets of cups are available in different sizes and are made
of thick glass. Bamboo cups can also be found but,
personally, I do not find them practical, especially when
it comes to sterilisation4. In addition, the bamboo version
tends to cause more discomfort, as the edges are thinner
than those of the glass cups. The Chinese accept some
degree of discomfort when treated but we, in the West
should try and make the treatment as pleasant as possi-
ble. Most suppliers prefer to sell the cups as a set, rather
than supplying single size cups. Most sets include one
very large, two medium, and one very small size. Cau-
tion should be exercised when washing glass cups as
they break quite easily.With bamboo cups there is no
danger of breaking. Both types of cups are easily obtain-
able from Chinese medicinal suppliers.
Before using cups
Before attempting to use cups, always make sure that
your patient is fully relaxed. Many people are nervous
about a fire lit next to their skin. Explain your intentions
and the benefits of cupping, and show the cups to the
patient (and let him or her touch and feel them). Most
people will tell you that they have indeed seen cups on
television programs and read about the technique but
have never actually seen it done to anybody. Explain that
the suction will cause a pulling sensation on the skin but
not pain. The suction is less noticeable with thin and
hairy people5, and more on smooth and fat skin. It is also
important that you ask your patient to sit still and not to
make sudden movements while cupping. If children are
involved, always ask the mother or father to be present
in the treatment room with you. It is advisable to try to
hide the fire from the child, in order to reduce their fear
to a minimum.
You can apply cups with the patient in a sitting posi-
tion, or lying prone or supine, whichever is the more
comfortable. For the elderly and for people with severe
asthmatic or heart conditions an upright sitting position
is advised.
Firm suction is desirable in order to achieve good
therapeutic results from cupping. To ensure good suc-
tion, always moisten the treatment area with oil. Any
vegetable oil will do, but olive oil is particularly benefi-
cial. Coconut oil may be used for more sensitive skins.
Avoid irritating oils such as Eucalyptus, Wintergreen
and Clove.
When and where to use cups
Cupping may be used by massage, acupressure (shiatsu)
and other tactile therapists, and integrated to suit their
particular technique. As far as acupuncturists are con-
cerned, cupping can be used independently or in con-
junction with acupuncture (while the needles are in
position or following their removal), although cups are
most frequently used on their own. Cupping therapy in
this country is unfortunately used by few acupunctur-
ists, and it makes me very sad to see so many acupunc-
turists who do not make use of this valuable traditional
2222
Chinese healing art. More emphasis on cupping and its
benefits during practical as well as theoretical training
would be helpful.
Benefits
Cupping regulates the flow of Qi (energy) and blood,
and can add strength and effectiveness to a great many
therapeutic applications. It is particularly beneficial in
the following situations:
- cold and wind attacking and penetrating the body
- Qi stagnation
- poor circulation
- weakness of the digestive system (poor appetite,
diarrhoea and dull ache in the lower abdomen)
- asthmatic conditions
- chronic back aches due to kidney energy deficiency
- on Ashi points to relieve blood stagnation
- to draw out pathogenic dampness, especially from
arthritic joints
The Eight Methods of Cupping
There are eight different methods of cupping: Weak,
Medium, Strong, Moving, Needle Cupping, Moxa Cup-
ping, Empty cupping, and Full cupping (bleeding).
Weak Cupping: this is done with minimum suction, just
enough to hold the cup in place.This type of cupping is
particularly suitable for debilitated patients and for chil-
dren. Cups are normally left for 10-20 minutes in adults
and 2-5 minutes in children, but in weak cupping they
can be kept in place for a longer period if needed.Weak
cupping should not induce bruising or any sensation of
pulling. If it does, then the suction is too strong, so
remove the cups and and re-apply. Each time new cups
are applied make sure that the skin is moistened with
enough oil.
Medium Cupping: with medium cupping, the suction is
firmer, and the skin rises just a little inside the cup. This
method is suitable for children between seven and four-
teen years of age. Medium cupping can also be applied
to adults on the stomach and abdomen. Very little bruis-
ing will appear even if the cups are left for a long time.
With a new patient, I usually start with medium cup-
ping, and increase the suction as the treatment progresses
- helping to build up the patient’s confidence. I would
advise all practitioners never to apply strong cupping at
the first consultation.
Strong Cupping: strong cupping should normally only be
used on patients who have experienced medium strength
cupping previously, so that they know what to expect.
Whenever strong cupping is used for the first time, it is
advised not to leave the cups in place for more than 3-5
minutes, and always massage the area after removing
the cups. This type of cupping is not suitable for children,
or weak or elderly patients. It causes bruising very
rapidly and drains the energy if the cups are left for a
long time. Strong cupping is best used on robust adults.
Strong cupping is not suitable on the abdomen or stom-
ach. and is mainly applied on the back, shoulders and
knees.
Moving Cupping: this is the most painful method of
cupping. It is done by moving the cups while they are in
 JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

place on the skin. It is mostly used in excess heat condi- nate poisons and infections from the body. The bleeding
tions, and only on strong adults. Whether the suction method is only used when excess Blood-Heat is in-
applied is medium or strong, movement of the cups volved. A small cut is made on the back - usually in the
while in place will be uncomfortable to say the least. upper part of the body - and the cup is placed over the
Before attempting the moving method, it is essential to cut. The vacuum created will draw blood into the cup
make sure that enough oil has been used on the desired which will fill rapidly. In Turkish folk medicine this
area. Also when moving the cups, rest between move- bleeding method was used when a sudden rise in blood
ments and apply massage to the bruised area. The most pressure endangered life (the face appears to be ready to
common area of application is the back, especially the burst with blood, the eyes are bloodshot, and there is a
Back-Shu points. The purpose of moving cupping is to feeling of heaviness over the shoulders and neck). The
draw out pathogenic heat and regulate the flow of blood. bleeding method should be used with caution and not
This will cause bruising very rapidly, which is the de- more than once a month. The amount of blood drawn
sired effect, indicating heat coming to the surface. It will may vary from half a cup to one cup at a time. Do not
be noticed that, as treatment progresses, less bruising apply this method on children or patients with weak
will appear in subsequent sessions. constitution. Careful sterile technique is essential both
Needle Cupping: cups can be applied over needles,whilst during and after the treatment.
the needles are in the desired position. Again this
method is used in Shi conditions, e.g. red, painful and Safety First
swollen knees and shoulders. With this method, some I always make safety a top priority when I use cupping
blood may be drawn into the cup. This is quite normal, treatment. I remember very clearly the tragic story of
especially if the suction how our neighbour
is strong. Obviously burned her husband to
one should not attempt death after attempting
the moving method cupping. The tradi-
while the needles are tional practice in Turk-
in position. ish homes, after cup-
Moxa Cupping: moxa ping, is to massage the
is placed on the needle patient with alcohol and
in the normal way for cover them in order to
warm-needle tech- promote sweating. In
nique, and lit. As soon this case the poor
as the moxa has woman used the alco-
stopped smoking, and hol to massage her hus-
while it is still very hot, band before she put the
place the cup over the cups on. Consequently,
needle. It is advisable as she struck the match,
to use a small piece of her husband caught fire.
paper or card over the He had a bad cold and
skin to protect it from instead of curing him,
hot ash. This method is she burned him alive!
used when tonifying This horrifying example
and moving the Qi. clearly emphasises the
Empty Cupping: this dangers of cupping if
is actually a strong cup- not correctly applied.
ping method, but the You must remember
duration of the suction that you are dealing
is very short, i.e. less with oil, alcohol and fire
than one minute, and all at the same time!
it can therefore be ap- Never rush when us-
plied to very weak per- ing cupping. When in a
sons, children and hurry you are liable to
adults. The technique make costly mistakes,
is easy: choose the cupping area and apply five to ten such as dropping the burning cotton wool on the carpet
cups simultaneously, then immediately remove the first (or worse on your patient). It takes a long time to build
one, replacing it with a new one. Continue replacing the up a successful practice, but it does not take long to make
cups until bruises appear. This may take up to 5 minutes. a bad name for your clinic. There should be no inflamma-
This method is very effective when the effect of “draw- ble objects nearby, like plastic bags or polyester covers
ing out cold” is desired, especially on Xu patients, since (cotton covers are warmer and safer).
it does not drain the energy excessively.
Full Cupping (Bleeding): with this method, the full un-
How to apply cups
derstanding and cooperation of the patient is essential. Prepare the cups beforehand, remembering to wash
In the 1830’s when antibiotics were unknown in Eng- them with soapy water after each use, to maintain clean-
land, this was the method used to draw out and elimi- liness and eliminate the risk of transferring perverse

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 JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991
energies between patients. If the cups have been in
contact with blood, soak in Miltons solution for twelve
hours or sterilise in an autoclave. Remember to explain
beforehand what you are about to do and why you are
doing it, and explain the importance of relaxing the
whole body.
Decide the location of the cupping; choose the size and
number of cups to be used, and take them close to the
location. Apply oil to the skin area to be cupped to ensure
a good suction (see above).
Suction is created by briefly introducing a flame into
the cup.This is done with a piece of cotton wool which is
held in a long pair of forceps, dipped into alcohol and lit.
Small rolls of cotton wool can be prepared beforehand
and kept soaked in alcohol in a tightly closed jar. Firmly
squeeze the cotton ball to remove any excess alcohol (to
prevent flaming alcohol dropping on to the skin). Hold
the cup in one hand, close to the skin, quickly and briefly
introducing the flame into the mouth of the cup, and
then turn it upside down and place it on the skin. In this
way suction is created and the cup will be held in the
desired position. The more you practice, the quicker you
will get. Suction strength can be regulated by the size of
the flame and the length of time you leave the flame in
the cup.
In winter months the glass cups are very cold, so before
the cups are turned on the skin, the rims should first be
warmed by briefly holding the flame just below the rims,
before introducing the flame into the cup. Over-heating
the rim of the cup can result in burning the skin of the
patient!
After applying the cups, cover the patient and keep
them warm. When the desired cupping time is complete,
remove the cups by pressing firmly with the index finger
between the base of the cup and the skin, allowing some
air into the cup for the suction to cease . The same index
finger pressing technique is used when the suction is too
strong and you wish to reduce the strength. When re-
moving cups, make sure that the cup is held away from
your face, to eliminate the risk of absorbing perverse
energies which have been drawn out 6.
After the cups are removed the skin becomes very
tender, so clean the area using soft paper, and apply
fresh oil while gently massaging the area to relax the
patient.
Where cupping is done for the first time, there will be
nearly always be a bruise mark at the site of application,
the degree of bruising depending on the strength of
cupping. In any case it will fade away in a week or less.
Summer holiday months are not the best time for cup-
ping, as patients will not be pleased when having to
explain unsightly bruises on exposed flesh. When cup-
ping is applied to the same area for a second time, bruises
are much reduced, and are even lighter at the third and
subsequent applications until they disappear totally as
the stagnation in the affected area disappears and the
flow of blood and energy is regulated. As a a rule, leave
the cups on for a shorter period the first session, and each
time cupping takes place they can be left for a longer
period, until the circulation improves and stagnation
disperses.
In some cases a blister can appear, particularly when
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strong cupping is applied on a very sensitive skin, e.g.
elderly people or children. It is preferable to stay with
your patient all the time and monitor the progress, and
if blisters start to appear then use your index finger to
reduce the suction.When blisters do occur, lightly pierce
the skin and let the fluid out, but do not apply cups to the
affected area until the blister heals.
Cupping on Children
Cupping is very safe for children over three years of age.
The reason for this age limit is the fact that the skin of a
child under three years old is very susceptible to blisters
and bruises. Children generally prefer cupping to acu-
puncture, but remember that some children are petrified
of fire, so take extra care to relax them before treatment.
I usually ask the mother if I can demonstrate the tech-
nique on her, and using her forearm, I put a small cup
there for the child to touch and feel. When I am con-
vinced that the child is ready I then proceed. Never force
cupping on a child if he or she is showing substantial
fear. When cupping children use small size cups. The
suction of these small cups is quite sufficient for chil-
dren. Give the cups to the child to see and hold. The
parent can help by holding the child and talking to them.
Children under five need most attention, so ask the
parent to hold the child firmly, as they can turn very
suddenly and touch your hand or try to push the flame
away. Once the cup is on they usually don’t mind at all.
The most common complaints for which cupping is used
on children include asthmatic and digestive conditions,
and all Back-Shu points can be used safely. One golden
rule when using cups on children is never to leave the
cups on for more than five minutes as this can cause bad
blisters and bruises and also drain the Wei-Defensive Qi.
The strength of the cupping should be low to medium,
but not strong.
Cupping on Adults
When using cups on adults one must consider the ener-
getic level and age of the person. I find that no matter
how healthy the elderly look, there is always an energy
deficiency. This is a normal energetic situation, so when
cupping is performed on the elderly, do not leave the
cups on for a long time, and do not use the strong method
as their energies can be drained, leaving them more tired
than when they arrived. Cupping time should also be
short, and a low to medium strength method used, on
younger adults with any deficiency syndrome. In syn-
dromes of Yang excess, the skin will be hot and tender in
places, and the cups can be left in place for longer time
(20-30 minutes) and the strong or moving method can be
used. The most common sites for cupping on adults are:
the knees (Xiyan), Zhongwan REN-12, Zhangmen LIV-
13, all Back-Shu points, the shoulders and points on the
lower back .
How often can cupping be used?
Cupping can be used every day until the condition
improves, but as this may not be practicable in western
countries, once a week is a typical frequency. One can
use cups on the same points even when the bruises are
not cleared completely. As mentioned earlier, it is rec-
 JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991
ommended to start cupping with a low to medium
strength, and increase the suction as the treatment
progresses.
Contraindications of cupping
i. Avoid strong cupping in the abdomen and stomach.
ii. Do not apply cups over scaly or burned skin. Do not
use cupping in any form on patients with Yin or Yang
depletion.
iii. During pregnancy never apply cups to the abdominal
or stomach regions, or back points, especially the lower
back. Otherwise cupping can be used with safety up to
the seventh month of pregnancy.
The treatment of common complaints
by cupping
Frozen Shoulder: Binao L.I.-14, Jianyu L.I.-15, Jugu L.I.-
16, Jianjing GB-21.
Knees: For painful and swollen knees Xiyan (Extra),
Liangqiu ST-34.
Digestive Complaints: Zhongwan REN-12, Zhangmen
LIV-13, Weishu BL-21. For Damp-Heat and stagnation
of Qi, use the same points but use the moving method on
Weishu BL-21 until bruises appear.
Digestive weakness (Spleen-Qi Xu): Riyue GB-24,
Zhangmen LIV-13, Zhongwan REN-12 and Pishu BL-20.
Lower backache: Mingmen DU-4, Shenshu BL-23,
Guanyuanshu BL-26, Pangguangshu BL-28 and Zhishi
BL-52.
Headache due to hypertension and Yang excess: Dazhui
DU-14 and Jianjing GB-21.
Asthma: Dingchuan (Extra - 0.5 to 1 cun lateral to Dazhui
DU-14) and Feishu BL-13.
Rheumatic and arthritic conditions: Use local points
and Dashu BL-11 (Influential point of the Bones).
Kidney Qi Xu: Jingmen GB-25, Mingmen DU-4 and
Shenshu BL-23.
Heat syndromes: All types of boils, furuncles, eczema
and psoriasis: Dazhui DU-14 and Geshu BL-17 (Influen-
tial point of the Blood). Also moving method can be used
on the whole length of the Back-Shu points until heat
comes up to the surface, indicated by the appearance of
bruising.
Hiccup: Strong method on Geshu BL-17 and Jueyinshu
BL-14.
Menstrual disorders: Zhangmen LIV-13, Riyue GB-24,
Dahe KID-12, Mingmen DU-4 and Guanyuanshu BL-26.
Bedwetting: Mingmen DU-4, Shenshu BL-23 and
Pangguangshu BL-28. As I mentioned earlier, bedwetting
is considered as lower back (Kidney energy) deficiency.
This condition is very common if children are frightened
or experience some kind of shock which drains their
Kidney energy.
Conclusion
Always remember the potential dangers of cupping
treatment; you are dealing with fire and alcohol at the
same time. Before lighting the cotton wool make sure
that you have squeezed out the excess alcohol. Inform
your patient, and familiarise and relax them before
applying the cups. Do not use strong cupping method or
long duration cupping at the first visit. Stay with the
patient in the cubicle and remove the cups if they are
hurting. When treating children ask the parent to remian
and help you if necessary. Blisters can form very rapidly
if the suction is strong; in this case remove the cups
without delay.
Be gentle when removing the cups, never pulling
them, but use the index finger pressing method at the
base of the cup and the suction will cease. Hold the cups
away from your face when removing and wash the cups
with soapy water. In cases of blood contaminating the
cup, hold the cup under running hot water and place in
a bucket with Miltons solution for twelve hours before
using the same cup again. Alternatively sterilise in an
autoclave. End the cupping treatment with a gentle
massage to the treated area and reassure your patient
that any bruising should fade away within a week.
Notes
1. Cold in the mother's milk: this is a very common
syndrome with mothers who breast-feed their chil-
dren. When the mother catches cold or over-indulges
in cold food, her milk may become thick and her
breasts painful. This condition is usually relieved by
massaging with warm olive oil and drinking hot soup
for a few days.
2. Women are prone to miscarry between 3 and 5 months.
In Turkish folk medicine this is said to be due to 'weak
back', the equivalent of Kidney-Xu in TCM.
3. First published in Great Britain by Cox and Wyman
Ltd, Reading, Berks.
4. I previously used Cidex solution for sterilising cups.
It has just now been brought to my attention that
Cidex solution is a highly dangerous carcinogenic
agent and should be handled with care. If used, the
room should be well ventilated and one should avoid
contact with the skin.
5. Bamboo cups can successfully be used over hairy
areas, using a light or medium method and with the
liberal use of oil. The cups can normally only be
retained for five to ten minutes before air seeps in and
reduces the suction.
6. By my understanding, heat represents energy in any
form and shape. During the removal of the cups, you
are bound to draw out some kind of energy, usually
CASE HISTORIES
1. Male, 9 years old
Complaint: asthma since birth.
Appearance: white forehead, wheezing, good build.
Phlegm: thick phlegm, worse in the mornings.
Medication: inhaler 5-7 times a day.
Diagnosis: chronic cold with retention of phlegm.
Treatment: Chize LU -5, Lieque LU-7 (needles), Feishu
BL-13, Pishu BL-20 (moxibustion), Dingchuan (Extra),
Feishu BL-13 (5 minutes cupping).
On the first five visits I used acupuncture and moxi-
bustion only, resulting in improvement in the wheezing
but still very thick and persistent phlegm. On following
25 25
 JOURNAL OF CHINESE MEDICINE NUMBER 37 SEPTEMBER 1991

weeks I added cupping to the treatment. After three such riasis sufferers is Yin-Xu and wind in the channels indi-
treatments the quantity of phlegm was significantly cated by dryness and itching. Reinforcing needling was
reduced, he was able to stop using the inhaler and was applied to Zhongwan REN-12, Zhangmen LIV-13, Qihai
much more active at school. He still continues treatment REN-6, Zusanli ST-36 and Sanyinjiao SP-6. Medium
once a month. cupping was applied to the Back-Shu points weekly to
help reduce heat in the channels and restore energy
2. Female, 45 years circulation.
Complaint: arthritic knees for five years. After three months of treatment her psoriasis has
Pulse: rapid at all levels. almost cleared. She has relapses with flare-ups espe-
Tongue: thick whitish coating. cially when under emotional stress and still comes for
Medical history: breast cancer surgery five years ago, treatment andCASE HISTORIES
evaluation once a month.
HRT for two years, generally feels tired and has stopped
working.
Diagnosis: Blood-Xu with phlegm retention.
Treatment: moxibustion and reinforcing acupuncture on
points such as Zhongwan REN-12, Zhangmen LIV-13,
Qihai REN-6, Zusanli ST-36 and Sanyinjiao SP-6, and
Needle-Cupping method at bilateral Xiyan (Extra) and
Liangqiu ST-34.
At the end of a course of treatment both knees were free
of pain and she was able to return to work.
3. Female, age 24
Complaint: psoriasis spreading all over the body, itchy,
thirsty.
Medication: various types of corticosteroids for three
years resulting in fine creases on the face.
Pulse: rapid.
Tongue: dry with red tip.
Diagnosis: Yin-Xu, wind, damp-heat rising.
Treatment: the most common syndrome I find with pso-

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