Cupping – 2,000 years of placebo effect and still going strong

In this blog our Senior Research Fellow, Ken Donaldson, looks at the history of cupping therapy and it’s modern day comeback.

Medical therapies have necessarily reflected our understanding of disease at the point in time that the treatment was offered. Since the understanding of disease has evolved and changed over time, the history of medicine is littered with examples of therapies that have fallen into disrepute and disuse. Leeches and blood-letting were used to deplete blood from the victim (sorry….I mean patient); suppositories containing the highly radioactive element radium were sold to restore ‘manly vigour’;  lobotomy, which involved cutting the brain with a knife, was touted as helping depression, and trepanning, drilling a hole in the skull, was wrongly believed to relive pressure that was supposedly causing neurological diseases- I could go on. The good news is that, as medical knowledge grew and the lack of a scientific basis for these ‘therapies’ became clear, they were abandoned and became a footnote, sometimes a shameful one, in medical history.

A common theme in some of these abandoned therapies reflects a theory of disease that held sway from the time of Hippocrates in ancient Greece, all the way to the 19th century. This theory, called the humoral theory of disease, held that the balance in 4 humors or liquids- blood, phlegm, yellow bile and black bile- controlled health in the body. If these 4 fluids were ‘in balance’, then health resulted, but if there was an imbalance, then disease ensued. It’s easy to see how the idea that a change in flow of fluids may result in ill health, given the appearance of fluids such as mucus, pus, diarrhoea and vomit during illness. A number of therapies were developed to increase the flow of these humours in sick and diseased people, including blood-letting, leeches, cupping and emetics, believing that this would restore balance and that health would be regained. It’s worth saying that there was never any evidence that some of these humors even existed, never mind proof that health depended on such humors being ‘in balance’. 

Early 19th century cupping glasses, sponge and 12-bladed scarificator, Surgeons’ Hall Museums.

As autopsies became more common in the 18th and 19th century, it became clear that disease was not diffuse or fluid-based, but could be traced to abnormal pathology in specific organs and tissues. So, for example, if a patient had a persistent cough with phlegm and became breathless and confused before dying, then at autopsy the place to look was the lungs. These were often found to be infected with tuberculosis and the seat of the disease was the lungs and not in some nebulous imbalance of fluids. This school of thought, known as anatomical pathology, was fostered by the likes of Morgagni in Padua and the Paris school, exemplified by Laennec and was sufficently advanced to entirely displace humoralism as the chief theory of disease by the middle of the 19th century. Ever since then evidence had accumulated to support this understanding of disease and no serious medical practitioner in the present day believes in the theory of humors in the face of the modern explanations of tissue pathology and disease development.

It’s therefore puzzling to see that cupping seems to be making a comeback as a treatment, as a quick search of ‘cupping’ on the web will confirm. Cupping was one of the treatments for humoral imbalance and involved applying cups of various sizes to the skin and then sucking the air from them by combustion or some other means, so that a mild suction is applied to the skin under the cup. Present day supporters suggest that cupping ameliorates pain and inflammation, whilst it assists in blood flow, relaxation and well-being. There is no pathobiological basis for expecting that sucking areas of skin up into a cup will do anything except cause mild inflammation, as evidenced by the red cupping bruises on the girl in the picture below.

A woman receiving fire cupping in Haikou, Hainan, China. Credit: Anna Frodesiak

However, a superficial review of the published literature reveals evidence that cupping has been reported to be beneficial in some cases. There might be a clue as to what is going on here by the fact that some elite athletes, who have no physical disease, use cupping in the belief that it helps them to win.  This argues for the famous ‘placebo effect’, whereby beneficial effects are produced by a treatment, but these effects cannot be attributed to the properties of the treatment itself and must therefore be due to the patients belief in the treatment. Placebo effects can be considerable, especially in pain relief and and in a subjective measure like ‘feelings of well-being’. There is nothing about cupping that a modern pathologist would recognise as being likely to have any of the effects claimed. Cupping can be seen therefore as another manifestation of the rise of ‘alternative therapies’, along with the burgeoning  anti-pharma and anti-medicine lobbies. If so, then we can expect a revival in blood-letting, emetics and cupping of the buttocks in the not-too distant future, dressed up as pseudo-science. But that’s the way the placebo effect works!

F. Dekkers, Exercitationes practicae,. Credit: Wellcome Collection.

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