Historical Perspectives and Unani/Persian Concept of Ḥijāma (Cupping Therapy): A Time-Honored Remedy for Various Health Ailments

Introduction

Ḥijāma (cupping therapy) is considered one of the oldest therapeutic procedures in traditional medicine worldwide (Turk, and Allen, 2009). The precise origin of Ḥijāma remains controversial; however, historical evidence suggests it has been practiced for thousands of years across various ancient civilizations. Arabic historians report that the Assyrians were among the earliest communities to practice Hijāma around 3500 BC, using primitive instruments such as animal horns and bamboo cups. In Arabic civilization, the therapy was known as Al-Ḥijāma (El Sayed, Mahmoud, and Nabo, 2013, p. 111; Ahmadi, Schwebel, and Rezaei, 2008, pp. 37-44).

Historical records also indicate that Ḥijāma was practiced in ancient Macedonia since prehistoric times (3300 BC) for the management of various diseases and health disorders (El Sayed, Mahmoud, and Nabo, 2013; Ahmadi, Schwebel, and Rezaei, 2008, pp. 37-44). Ancient Egyptian civilization recognized Ḥijāma as one of the earliest medical therapies. Evidence of its use dates back to approximately 1550 BC, as documented in the famous Ebers Papyrus. Illustrations depicting cupping instruments have also been identified in the tomb of King Tutankhamun and on the walls of the temple of Kom Ombo, which served as a major medical center during that period (El Sayed, Mahmoud, and Nabo, 2013, p. 111; Ahmadi, Schwebel, and Rezaei, 2008, pp. 37-44; Christopoulou-Aletra, and Papavramidou, 2008, pp. 899-902). In ancient Egypt, Hijāma was utilized not only for the treatment of diseases but also for the preservation of general health.

In Traditional Chinese Medicine, cupping therapy has been practiced for more than 2000 years (El Sayed, Mahmoud, and Nabo, 2013, p. 111; Chirali, 1999, pp. 73-86). Its therapeutic application was first systematically documented by Ge Hong (281–341 AD) in the Handbook of Prescriptions for Emergencies (Hanan, and Eman, 2013, pp. 631-642). From Egypt, the practice spread to Greece, where cupping became closely associated with medicine. Renowned Greek physicians such as Hippocrates and Galen strongly advocated the use of Ḥijāma. Hippocrates (460–377 BC) provided detailed descriptions regarding the shape, size, and application of cups, recommending smaller and lighter cups for deep-seated disorders and wider cups for superficial conditions (Mahdavi, 2012, pp. 67-88). Although he mainly promoted dry cupping, he also endorsed limited use of wet cupping for bloodletting purposes.

During the Roman era, physicians such as Celsus and Galen further popularized Hijāma and bloodletting therapies for the management of localized and systemic diseases (Turk, and Allen, 2009, pp. 9-15). In Persian medicine, Ḥijāma also occupied an important therapeutic position. Ibn Sina (Avicenna), in his renowned work Al-Qanoon fi al-Tibb, described Ḥijāma as a significant therapeutic modality for disease management (Avicenna, 2010, p. 537). The practice of Ḥijāma in Europe and the Middle East evolved alongside humoral theory, which emphasized the balance of the four humours: blood (dam), phlegm (balgham), yellow bile (safra), and black bile (sauda). Prominent physicians, including Galen, Paracelsus, and Ambroise Paré, advocated cupping therapy, which was also commonly practiced by barber surgeons and bath attendants (Ullah, Younis, and Wali, 2007).

In the seventeenth and eighteenth centuries, several European physicians, including Sydenham, Willis, Pitcairn, Mead, and Heberden, continued to recommend Hijāma as a therapeutic intervention (Turk, and Allen, 2009, pp. 9-15). In recent decades, there has been growing global interest in Hijāma and other complementary and alternative therapies, particularly in Asia, the Middle East, Europe, and the United States (El Sayed, Mahmoud, and Nabo, 2013, p. 111). In Korean Medicine, cupping therapy is commonly employed to enhance the circulation of qi and alleviate blood stasis through negative pressure and suction techniques. A recent survey among Korean medicine practitioners reported that Ḥijāma is predominantly used for musculoskeletal disorders, particularly involving the neck and shoulder regions (Kim, et al., 2011, p. 146).

Three different treatment modalities are detailed in the traditional textbook of Unāni medicine, namely, ‘Ilāj bi’l Tadbīr (Regimenal therapy), ‘Ilāj bi’l Taghdhiya (Dietotherapy), ‘Ilāj bi’l Dawā’ (Pharmacotherapy), and ‘Ilāj bi’l Yad (Surgery). ‘Ilāj bi’l Tadbīr (regimenal therapy) is one of the most popular methods of treatment practiced by ancient Unāni physicians for ages. Regimenal therapy is a modification of Asbāb Sitta Ḍarūriyya (six essential factors) and the application of regimens for maintenance of health as well as for disease management. The six essential factors are Air (Hawā’), Food and Drink (Makūl wa Mashrūb), Al-Ḥaraka wa’l Sukūn al-Badanī (bodily movement and repose), Al-Ḥaraka wa’l Sukūn al-Nafsānī (psychic movement and repose), Al-Nawm wa’l Yaqẓa (sleep and wakefulness), and Al-Iḥtibās wa Al-Istifrāgh (retention and evacuation). Various therapeutic regimens are included under Ilaj-bit-Tadbeer, such as Ḥijāma (Cupping), Ābzan (Sitz bath), Hammam (Bathing), Dalk (Massage), Takmeed (Fomentation), Irsale-Alaq (Leeching), Fasd (Venesection), Ishaal (Purgation), Riyazat (Exercise), Qai (Emesis), and Idrare Baul (Diuresis). These regimens may be used independently or in combination with other therapeutic modalities. These are essential for every person, and an imbalance in any or all of these factors may lead to various disease conditions. These regimens may be used independently or in combination with other therapeutic modalities (Wani, et al., 2023, pp. 117-132).

The term Ḥijāma is derived from the Arabic word “Hajm,” meaning “to suck” (Dar, and Lone, 2015). It refers to a therapeutic procedure in which a partial vacuum is created inside cups applied to the surface of the body using heat or mechanical suction. This technique is employed to evacuate morbid materials, divert harmful substances from deeper tissues, and enhance blood circulation at the affected site (Dar, and Lone, 2015; Anjum, et al., 2005, pp. 412-415; Tagil, et al., 2014, pp. 1032-1036). The word Hijāma also carries different meanings in Arabic literature, including the removal of scalp hair and the application of cups (Seenghi) (Alam, et al., 2012, pp. 143-148). In the present review, an attempt has been made to elucidate various aspects of Hijāma in the Unāni system of medicine.

Materials and Methods

This review study on Ḥijāma was searched in classical Unāni textbooks available in the Kashmir Tibbia College Hospital and Research Centre library, such as Al-Qanoon Fit Tib. Vol. 1 & 3 part 2 (Urdu Translation), Kitabul Hawi. Vol. 11, Firdous ul Hikmat, Kaamilus Sana’ah (Urdu Translation), Kitab al-Taisir Fil-Mudawat Wal-Tadbeer, Kitab Al Mukhtarat Fit Tib. Vol. 1 & 4, Matab E Hakim Alwi Khan (Urdu Translation), Tibbe Akbar (Urdu Translation), Akseere Azam (Al Ikseer) (Urdu Translation), Jami-ul-Hikmat. For a comprehensive review of Ḥijāma, major scientific databases, including PubMed, ScienceDirect, and Google Scholar, were systematically searched. Additionally, the Standard Unani Medical Terminology was consulted to identify appropriate English equivalents for the Unāni terms used throughout the article.

Synonymous

Hijamat, Al-Hijāma, Seenghiyan khichwana, Seenghiyan Lagwana, Pachney lagwana, Sheshay Lagwana and Jiaofa and Baguanfa (Chinese) (Nafisi, 1954, pp. 432-433; Qurshi, 2011, p. 123).

Classification of Ḥijāma

There are various types of cupping as mentioned in Table 1.

Conditions of Ḥijāma bi’l Sharṭ Ikhtiyāriyya

Al-Masihi mentioned the following conditions for Hijāma bish shart ikhtiyari (Masihi, 2000, pp. 95-96; Ahmedi, and Siddiqui, 2014, pp. 1-14);

1. It should be performed mid-day of the lunar month calendar (Jurjani, 2010, pp. 403-405)

2. It should be performed in sah paher (afternoon) because this time is most suitable for Hijāma.

3. It should be performed in the summer. In this season, the Akhlat (humours) become less viscid due to increased Hararat and are easily evacuated through cupping.

4. It should be performed in those persons whose blood is relatively less viscid.

5. It should be performed after the use of syrups having muqawwi-i-mi’da and dafa’-i-mawäd properties.

6. It should not be performed in weak and cachexic persons (Qurshi, 2011, p. 127).

7. It should not be performed by anyone under 2 years of age or after 60 years of age (Qurshi, 2011, p. 127; Jurjani, 2010, pp. 403-405; Avicenna, 2010, p. 538).

8. Ḥijāma is not recommended immediately following Hammām, because the skin becomes dense and may necessitate deeper incisions to facilitate bloodletting, which can cause considerable pain and physical debility. Moreover, the procedure should be avoided in individuals with thick and viscid blood, especially those who are obese.

9. Ḥijāma should be avoided immediately after sexual intercourse.

10. Ḥijāma should not be performed immediately after strenuous physical activity, as excessive exertion and dehydration may lead to generalized weakness. However, it may be considered in individuals with a robust physique and thick or viscid blood.

11. Ḥijāma is contraindicated in persons experiencing bodily weakness and laxity resulting from excessive depletion or dissolution of body tissues.

Contraindications for Ḥijāma

1. Ḥijāma should be avoided in individuals suffering from anemia, which may be identified by the physician based on the patient’s physical appearance and pulse examination (Nimrouzi, et al., 2014, pp. 128-136).

2. Ḥijāma should preferably be avoided in cold climatic conditions. In unavoidable circumstances, only a small amount of blood may be removed, ideally during the later part of the morning (Nimrouzi, et al., 2014, pp. 128-136).

3. If the causative matter is in abundance, then Fasd (venesection) should be done before Hijāma. Fasd evacuates the morbid material from the body in general, while Hijāma bish shart does that from the affected organ in particular (Qurshi, 2011, p. 128).

4. Hijāmah bi’l Shart should be avoided in pregnant women, especially during the first five months of gestation, and is also not recommended during menstruation (Mohammad, Fasihuzzaman, and Jabeen, 2015).

5. The procedure should be performed in individuals with a moderate body build, avoiding those who are extremely obese or excessively thin (Qurshi, 2011, p. 128).

6. Hijāmah bi’l Shart is recommended only after at least 12 hours have elapsed following intercourse and 3–4 hours after food intake (Nimrouzi, et al., 2014, pp. 128-136).

7. If the aim is to divert the matter from Shareef uzw to adna uzw, it should be done before the appearance of the peak stage of inflammation (Qurshi, 2011, p. 128).

8. The consumption of certain dietary items, especially eggs, is discouraged for at least 4–6 hours before and after cupping therapy (Nimrouzi, et al., 2014, pp. 128-136).

9. Lean individuals with a hot and dry temperament are advised to take pomegranate juice or chicory with sugar, as this may help prevent the development of unhealthy humours in the stomach. In contrast, other individuals should refrain from eating for approximately three hours after the procedure (Qurshi, 2011, p. 128; Nimrouzi, et al., 2014, pp. 128-136).

Indications of cupping in Unāni Medicine

The therapeutic indications of cupping, categorized according to the type of cupping and anatomical sites, are presented in Tables 2 and 3.

Unani Concept of Mechanism of Action

In the Unāni system of medicine, cupping therapy functions in two ways (Lari, et al., 2017, pp. 21-24; Avicenna, 2006, p. 539; Al-Bedah, et al., 2018, pp. 90-97):

1- Tanqiya’-i-Mawād (cleansing of morbid matter)

In Unani literature, disease is considered to arise from an imbalance of the Akhlāṭ (humours) leading to the accumulation of morbid material at specific sites within the body. Ḥijāma bi’l Sharṭ acts on the principle of Tanqiya’-i-Mawād and hereby facilitates the removal of morbid substances from the affected region (Lari, et al., 2017, pp. 21-24; Avicenna, 2006, p. 539). Jālinus stated that when the humours become dense and stagnant within the joints, Ḥijāma proves particularly beneficial in dispersing and evacuating these accumulated materials. It increases blood circulation, dilates the cutaneous pores, improves tissue nourishment with the supply of fresh blood, and strengthens the body’s eliminative. Through these actions, it assists in the evacuation of Akhlāṭ-i-Fāsida (morbid humours) and helps restore humoral equilibrium by eliminating deranged qualities such as Hār (heat), Bārid (cold), Raṭb (moistness), and Yābis (dryness) (Lari, et al., 2017, p. 21-24).

2- Imāla--i-Mawād (diverting morbid matter)

Ḥijāma bilā Sharṭ (Dry Cupping) operates on the principle of Imāla-i-Mawād (Diversion). This technique involves moving morbid material from one location to another. Through this process diversion, Ḥijāma bilā Sharṭ enables Ṭabī‘at Mudabbira-i-Badan to resolve the morbid matter. Ḥijāma bilā Sharṭ helps relieve congestion, resolve obstructions, and restore the normal flow of blood circulation, thereby reducing muscular tension and pain. It is also believed to divert inflammation and pressure from the deeper vital organs, particularly the heart, brain, lungs, liver, and kidneys, towards the skin and superficial tissues of the body.

As a result, the immune system is strengthened, and the healing process is facilitated, promoting the body’s optimal functioning (Lari, et al., 2017, pp. 21-24; Avicenna, 2006, p. 540).

Mechanism of action in modern medicine

Although the exact therapeutic basis of Ḥijāma has not yet been fully elucidated, several theories have been suggested to explain its mode of action and the diverse effects produced by cupping therapy. The cupping session is linked to biological and mechanical processes, according to several researchers. (Lari, et. al., 2017, pp. 21-24; Al-Bedah et. al., 2018, pp. 90-97; Anees et.al., 2015, pp. 88-100) (Table 4).

Pain Gate Theory: According to this concept, pain impulses are carried from the affected area to the brain through specific pathways. The application of a cupping cup creates another sensory stimulus that interferes with these pain impulses, thereby reducing the perception of pain through the same pathway. (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Reflex Zone Theory in Cupping Therapy: According to this theory, dysfunction in an internal organ produces reflex changes on the corresponding area of the skin, which may manifest as redness, tenderness, or swelling. When cupping is applied, the cutaneous receptors are stimulated, leading to improved blood circulation and enhanced blood supply to both the skin and related internal organs through neurovascular reflex mechanisms (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Prostaglandin theory: Inflammation in the body leads to the production of prostaglandins, which play an important role in transmitting pain impulses to the brain. Ḥijāma bi’l Sharṭ is believed to help eliminate these inflammatory mediators from the body, thereby contributing to pain relief (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Endorphins and encephalin production theory: These are endogenous pleasure compounds, which are natural substances produced by our bodies and which reduce pain.91,99

Nitric Oxide Theory: According to this theory, nitric oxide is an important biological mediator released in response to tissue injury and is also believed to be produced during or after Ḥijāma bi’l Sharṭ (wet cupping). Nitric oxide exerts several beneficial effects, including vasodilatation, improvement of blood circulation, relaxation of smooth muscles leading to relief of spasms, anti-thrombotic activity, and anti-inflammatory action. It also helps prevent narrowing of blood vessels, thereby promoting better vascular function (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Taibah theory: According to Taibah theory, the skin is raised when negative pressure (suction force) is exerted using cups on the skin’s surface because the skin is elastic. The gradual expansion during cupping reduces local capillary pressure according to Boyle’s law, leading to increased capillary filtration and accumulation of lymphatic and interstitial fluids in the skin. This decreases pain by dilating chemical substances, inflammatory mediators, and nociceptive substances, bathing nerve endings in gathered fluids, and rupturing tissue adhesions (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100). According to the Taibah theory, Ḥijāma bi’l Sharṭ is considered a minor excretory surgical procedure that facilitates the removal of pathological substances from the body, in a manner comparable to renal glomerular filtration and abscess drainage. (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Chinese Theory: According to practitioners of Traditional Chinese Medicine, diseases arise due to stagnation or blockage in the flow of Qi (vital energy). Cupping therapy is believed to restore the normal flow of Qi by removing these obstructions and re-establishing the body’s natural balance (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Analgesic effects of cupping therapy: The mechanical stimulation and minor skin injury produced during wet cupping therapy may activate Aβ nerve fibers and inhibitory neural pathways at the spinal cord level, thereby modulating pain perception. The superficial skin incisions and negative pressure created during the procedure draw out a small quantity of blood and generate a nociceptive stimulus, which may activate diffuse noxious inhibitory control mechanisms. This response is believed to reduce chronic musculoskeletal pain, including its emotional and affective components, through modulation of limbic system activity. Therefore, the analgesic effect of wet cupping therapy may be attributed to both tactile and nociceptive stimulation produced during the procedure (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Increasing blood circulation theory: Cupping therapy is believed to improve blood circulation, relieve congestion, and facilitate the removal of inflammatory substances and toxins from the tissues, thereby helping to reduce inflammation and pain (Lari, et al., 2017, pp. 21-24; Al-Bedah, et al., 2018, pp. 90-97; Anees, et al., 2015, pp. 88-100).

Scientific studies on cupping therapy

Several clinical studies and case-based investigations have highlighted the therapeutic potential of cupping therapy across diverse clinical conditions. Kousar, et al., (2024) demonstrated that wet cupping significantly improves symptoms of cervical spondylosis. Similarly, Begum et al., (2023) reported that dry cupping, when used adjunctively with Unani medicine, is effective in managing primary dysmenorrhea. In another study, Khatoon et al., (2024) found that wet cupping offers notable clinical benefits in patients with rheumatoid arthritis.

Research by Kalam, Suhail, and Ibrahim, (2024) further supports the efficacy of cupping modalities, showing that wet cupping combined with Unani therapeutic measures is beneficial in chronic migraine. In a separate investigation, Kalam, Jalal, and H, (2024) also reported the effectiveness of dry cupping in improving functional outcomes in patients with frozen shoulder.

Conclusion

Ḥijāma is a significant therapeutic modality of ‘Ilāj bi’l Tadbīr in the Unani system of medicine that primarily functions through the evacuation and diversion of morbid substances from the body. Contemporary studies indicate that Hijāma may contribute to health promotion and disease management, serving both preventive and therapeutic purposes. It has demonstrated potential benefits in a variety of disorders, particularly those related to the musculoskeletal, reproductive, circulatory, and nervous systems.

Despite its growing acceptance in complementary and integrative medicine, further scientific validation is required to establish its efficacy according to modern medical standards. The development of standardized operating procedures (SOPs), evidence-based guidelines, and methodological research protocols is therefore essential. Future investigations involving large sample sizes, randomized controlled trials, and long-term follow-up conducted by qualified clinicians and researchers are strongly recommended to evaluate the clinical effectiveness and safety of Hijāma in diverse disease conditions.

Acknowledgements

We are thankful to the library staff of Kashmir Tibbia College Hospital and Research Centre for their support in compiling this work.

Authors’ Contribution

Khalid Rahim Wani conceptualized and curated the study plan, conducted the literature review, analyzed the collected information, and drafted the original manuscript. Abdul Nasir Ansari assisted in the literature survey, contributed to the manuscript revision, and provided critical editorial input. Mohd Nayab performed the final review and proofreading of the manuscript. All authors read and approved the final version of the manuscript.

Funding

None.

Conflict of Interest

None.

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