feature

A cupping mark
is not a bruise

By Bruce Bentley about before, and unfortunately there is a

common notion that cupping marks are
This essay offers some practical insights into cupping marks bruises; hence they are often mistakenly
referred to a cupping bruises. The term
and explains why they should not be interpreted as bruises.
discolouration should also be avoided
as it gives the impression of being either
undesirable or some form of skin pathology.

T
HERE IS NO procedure performed in The no-fuss term cupping mark should
current medical practice, or in any other be adopted because among the people of
activity in our present-day culture, that diverse cultures who have traditionally
familiarises us with the idea that the marks practised cupping, a technical or official
that can be produced by cupping are the out- title has never been given for them. They are
come of a positive and beneficial therapeutic quite simply a matter of routine in the course
process. It is understandable therefore that of treatment. While the Chinese call them
they can be both perplexing and confronting, yinzi, meaning marks, the Greeks in north-
and it is not hard to imagine patients asking western Thessaly for example use the term
themselves, How can these marks be consist- dachylidia indicating rings. In the words of
ent with a therapeutic procedure? Mrs Fontini Stravou from the mountainous
The time has arrived to clear up any village of Koniska in central Greece: A bruise
uncertainties and highlight the positives is due to an injury to the body. The cupping
because, apart from some brief accounts, mark is a different thing. In Greece we dont
I believe the topic has never been written regard cupping marks as bruises. And Mrs

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Maria Petariki, who was born and lives in Indications of proof

Hania, Crete, explained: The more coldness To date there has been no published research
and pain, the darker (blue and purple) the on the substance of the cupping mark, nor
marks are. They are a good thing. to my knowledge are there any trials under
Those who grow up with cupping way. Nevertheless, it could be argued that
know that the mark is a meaningful and cupping marks actually fulfill a number
encouraging indication that some variety of of essential scientific prerequisites. Their
pathogen(s) has been brought to the surface characteristics are repeatedly displayed as a
by the drawing power of the cupping vessel. catalogue of diagnostic indicators consistent
It is a visible sign of success, and is in no with a well-developed classificatory index
way unnatural or at odds with any stage of of observed and sensory-based criterion,
the healing process. As a point of emphasis, that have been tested and accepted by all the
it should be understood that this does not worlds scholarly medical systems, except
mean that cupping without producing marks biomedicine, as well as by all the folk medical
n Bruce Bentley began
has been unsuccessful. Some of the instances traditions since antiquity.
learning cupping dur-
where marks are not brought about include Given cuppings longevity and the trust
ing a five-year program
performing a light form of Russian cupping that many people have in its efficacy, it is
in Chinese medicine in
massage for relaxation, restoring vitality and a living heritage that is rare in this ever- Taiwan from 1976-1981.
spirit after illness or emotional distress with changing world. I hope that in the near Later, for three months in
soft cupping to achieve a similar effect to future we will see a shift in our medical way 1998, he was invited to
light massage done with tender loving care of thinking to a more flexible model able study and exchange ideas
to recuperate the body and soul, and the to accommodate different paths of healing with cupping and gua sha
powerful effect of applying a cup with the and alternative systems of patient response specialists at the Shanghai
softest and most delicate touch down on analysis, rather than being geared to objective Hospital of Traditional
the skin imaginable to restore strength and and reductionist standards. Chinese Medicine, before
integrity to chronic tissue weakness (Bentley, In addition, it is worth bearing in mind studying cupping at
2011). that if not for its long cross-cultural career, the Tibetan Hospital of
Thinking of cupping marks as bruises may in all probability we would not even have Traditional Medicine. He
also conjure up the notion that they must the practice of cupping today, since from the has an Honours degree in
be the result of a painful procedure. On very beginning of the biomedical era around Sociology (of Health and
the contrary, cupping performed correctly, the 1880s, the newly emerging fraternity did Illness), a Masters degree
with the appropriate choice of method all it could to discredit traditional practices in Health Studies with his
and the correct level of suction to suit the including cupping and their explanations thesis titled Cupping as
patients strength and condition, is always a concerning how we get sick and how best to Therapeutic Technology,
comfortable and satisfying experience. deal with pain and illness. Distilled simply, and has researched exten-
Furthermore, an even more problematic in order to secure exclusive legitimacy sively throughout Europe,
issue arises when cupping (and gua sha)
1
for its practitioners and attain medical North Africa and Asia. You
dominance, as well as provide a platform can find his recent chapter,
marks are misinterpreted as signs of abuse
Cuppings Folk Medical
(Asnes and Wisotsky 1981, Eagle, Manber for pharmaceutical companies to prosper,
Heritage: people in prac-
and Kanzler 1996, Davis 2000, Morris 2000 Western medicine required a total separation
tice in Ilkay Chiralis book
et al). Only a little over 10 years ago I was from the past. Ironically, only 50 years earlier,
Cupping Therapy (3rd Ed.)
nominated by Vietnamese community Thomas Wakely, the editor of the Lancet (the Bruce is now working on
leaders in Melbourne to head a 12-month celebrated British journal of medicine) wrote a book titled The Greek
research project funded by the Department of the preface to Samuel Bayfields book The Art Cupping Tradition.
Human Services (Victoria) titled Folk Medical of Cupping (1823) urging medical students to n Visit www.healthtradi-
Practices in the Vietnamese Community. A explore its contents because those who are tions.com.au for informa-
pressing concern for the community was to conversant with the subject will be amply tion about Bruces work-
2
see an end to this serious error of judgment. repaid... shops, essays and cupping
One of the documents produced was sent to The only kind of techno-science based equipment.
all doctors and teachers throughout Victoria information to relate is what I was told n Join Bruce on Facebook
explaining the rationale and meaning of during three days spent observing therapists for more discussion about
the marks according to culturally informed performing stationary and sliding cupping cupping marks at:
practice, and how to distinguish them from at the Australian Institute for Sport (AIS) facebook.com/
bruises and inflicted maltreatment. some 20 years ago. The head massage HealthTraditions

The Lantern 15
 feature

therapist at the time, Barry Cooper, said The stages of a cupping treatment
one athlete was cupped and a round black According to every cupping tradition,
mark produced. Immediately a tissue sample the marks are always the result of certain
Blood without was whisked off to a nearby laboratory for pathological agents being released from deep
movement is no microscopic examination to determine the within the body, or from the superficial level
longer functioning as composition of the dark pigmentation. The including the subcutaneous skin layers and
blood and becomes finding was old blood. It can be presumed the fascia. Long experience concerning the
a stagnant agency this was bound in a muscle and drawn to the mechanism of cupping and the appearance
detrimental to health. surface, just as a pool of blood resulting from of cupping marks can be summarised as
a corked thigh can occupy the tissue spaces follows:
within a muscle belly and be liberated to Cause: Injury, tension and climatic effects
the surface by cupping. It follows as logical such as coldness (often felt deep within
that the longer that blood is not moving, chronic injury), wind (including drafts and
the more it thickens, congeals and darkens. air-conditioning causing head and muscle
Indeed blood without movement is no aches) and heat (counting blow heaters that
longer functioning as blood and becomes a can cause dry hot throat and other febrile
stagnant agency detrimental to health. There reactions) are among the most important
is no better way of shifting blood stagnation precursors why we suffer illness and pain.
than with cupping, and in such cases you can Method: Cupping is an efficient and
be guaranteed that a dark mark is going to rational means of withdrawing the
be produced. There is also every chance that infiltration and cumulative effects of these
following treatment the persons pain will be internal and external etiological factors.
greatly relieved. Marks: Are the physical outcome of
Stefan Becker, a Brisbane based chiropractor, pathogens, toxins, blockages and impurities
adds another plausible dimension to the (waste products) that are an undesirable
discussion: If the muscles are chronically presence in the body.
tight in an area, the muscle contraction Result: Having been freed from inside
could restrict blood vessels, slowing down and drawn to the skin surface, a pathogenic
blood flow which could thicken the blood influence causing a cupping mark is resolved
through platelet activity. Cupping could in two ways. Some of it passes directly from
draw stagnant blood and toxins through the the body into the atmosphere, and a certain
muscle to restore blood flow in these areas amount is resolved by innate dispersing
of chronic myospasm. The act of cupping processes that function at the superficial
would also bring phagocytic activity to the level, including the local blood supply and
area thus cleaning it up. lymphatic activity. Pertaining to cupping
Coincidentally, the AIS laboratory and its influence on the fascia and the
old blood finding strikes a chord with ground substance (Bentley, 2013) means
traditional interpretations concerning dark it is also likely to promote an additional
cupping marks, and confirms that old or bad immunological boost to what Paoletti
blood has been dormant within the body for (2006:158) describes as the first defensive
a long time. The finding of old blood also barrier.
lends credibility to those scholarly and folk
medical systems that often refer to pain being Mapping locations of pain & illness
caused by bad blood. Critics with vested In 1998, a chemist in Ioannina, north-
interests, and with little or no experience of western Greece, by the name of Dr Zarharhin
the subject matter, typically speak of this described cupping as a very good practical
concept in disparaging terms. technique. He added, People who do it look
In this light, it is limiting and ill-informed at the picture of the back, meaning that the
in every sense to regard the marks as some indications of pain and illness are delivered
sort of undesirable outcome to be avoided at to the surface and there to be observed. The
all costs. It should be worthy to know as well significance of the marks is highlighted in
that once a patient is in the know, they often the following case.
even become proud of their marks and for In Ioannina I observed a group of men
good reason, as we will now discover. gathered around a man who was performing

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traditional (glass and flame) cupping on his comprehensive and methodical reckoning
friend who had developed the flu earlier that available on this subject. In folk systems
morning. The protocol he used went like such as Greek, Lithuanian and Vietnamese It is telling that many
this. Five glass-cupping vessels were rapidly practice nowadays, the evaluation of cupping
massage therapists
applied to one area of the upper back. marks does not pick up on the same degrees
Immediately following the application of of variation or subtlety.
who receive cupping
the fifth cup, the first cup was taken off and for the first time to
reapplied to a new site. So too the second n Cupping marks that display a fresh red the margins between
cup, then the third, fourth and fifth. This colour indicate a recent traumatic injury the three deltoid
procedure went on until the five cups had with accompanying heat. heads frequently
each been reapplied bilaterally throughout display dark marks.
the entire back from the upper margins of n Black, deep purple or deep blue indicates
the trapezius muscles down to around T10 blood stagnation (Pic 1). It occurs when an
and including the sides. This entire process injury or illness (including strong coldness
3
was then repeated another four times. inducing blood stasis) has resided in the
When completed, the oldest man, who body for a long time. A robust exogenous
appeared ancient, arose slowly from his pathogenic agent such as the combination
chair, shuffled around the table and pointed of wind with cold can also quickly
his spindly index finger at each of the four manifest as a dark mark. It is telling that
locations where a very dark cupping mark many massage therapists who receive
had appeared. Each time he did this he cupping for the first time to the margins
fixed me with a stern gaze and growled between the three deltoid heads frequently
with satisfactionto the merriment of the display dark marks. This indicates that the
others until finally his mouth transformed shoulder girdle has become congested due
into a knowing smile as he curled back his to over-use. It is recommended that MTs
finger and made a thumbs-up gesture. The get cupping to these spaces on a monthly
blatant hue of each mark identified where basis to keep the region in good order.
the major concentrations of the offending
cold pathogens were located. The man who n A light pink or pale blue mark indicates
performed the cupping then resumed with mild coldness. (See the essay Cupping
4
part two of the treatment. He reapplied a Deficiency )
cup on each of the four-standout marks
for two to three minutes to withdraw any n A pale or white mark that fades quickly
residual pathogenic coldness from deeper indicates a lack of energy and function (qi).
levels of the body. In this case, it is important
that the strong stationary cup is left active n A mottled presentation comprising
for no more than a few minutes, otherwise crimson (or red) and white or lighter
its action becomes reducing and sedating elements represents the condition where
which would be called for when treating deficient body energy (whiteness) impedes
tight hard muscles but is not appropriate the blood circulation (redness). (Pic 2.)
when the focus is to draw out pathogenic
influences without reducing the strength n Red dotting indicates the presence of a heat
of the body. Due to his acute condition, the toxin due to blockage causing pent-up
men suggested that he get treated one time heat, which the Chinese call sha (Bentley,
per day for three days in a row. 2011). These small bright-red dots also
commonly result from sliding cupping,
Marks as diagnostic fact finders which due to its constant state of motion
The list below identifies an array of tends to draw from more superficial levels
cupping mark presentations as they occur compared to stationary cups, which draw
immediately after a cupping vessel has been from the full entitlement of depth possible.
removed from the skin, as well as a brief Even when slowly sliding silicone-cupping
diagnostic synopsis of each. This differential vessels to rectify the fascia using the
analysis is based on traditional Chinese modern cupping technique, the innate
medical thinking, which offers the most mechanism of drawing outwards will

The Lantern 17
 feature

sometimes inevitably cause certain factors

lying within the underlying tissue to
emerge at the surface. Sha made apparent
by cupping typically resolves in a short
period of time. (Pic 3).

n A protrusion (an elevation above the

regular surface level) of a tight black or
purple knot of tissue indicates clotted
dormant blood of fixed location that by
degrees of form can even look similar to
a varicose lump. It is a source of sharp
stabbing long-term pain and immobility.
No other method can draw this from the
body like cupping. In Vietnamese practice, Pic 1: A mottled cupping mark indicating
both the cause and the manifestation insufficient strength (paleness) and slug-
are called poison wind. Sometimes an gish circulation producing mild blood sta-
elevated hard knot, which at its centre is sis (crimson/purple). When this evidence is
white or paler than the surrounding tissue noted, flash cupping performed by rapid
emerges and indicates cold phlegm. The on and off applications revives energy and
vacuum effect of cupping can produce a moves the blood. It is a soothing and toni-
soft and full-bodied swelling contained fying method that restores the integrity to
within the parameter of the cupping vessel. soft tissue and removes dull or intermit-
This will diminish quickly. It represents tent pain and feelings of weakness.
generalised oedema (dampness).

n In the absence of a cupping mark, sometimes

droplets of clear fluid can be seen within
the interior of a cup. On occasions also,
a sticky dull yellow mucosal-type residue
is observed towards the inner apex of a
cup. Clear water type droplets indicate
dampness escaping beyond the protective
skin layer, while thicker residues indicate
the discharge of phlegm caused by heat
drying regular fluids.

n On rare occasions, a blister or blisters

containing fluid may appear inside
the perimeter of a stationary cup. This Pic 2: This very defined cupping mark is
indicates the local area has superficial located above a medically diagnosed par-
oedema (dampness). Caution needs to be tially torn middle deltoid muscle injured
taken to keep the area free from infection. nine months before this photo was taken.
The blisters should be carefully wiped It identifies blood stagnation and features
with antiseptic, then covered with a sterile a proliferation of black, slightly elevated
pad and left to reabsorb into the body. blood clots and swelling, reflecting deep,
Regrettably, a cup applied too strongly and sharp persistent pain and immobility.
left on the body for more than 20 minutes
may also cause blisters. Some practitioners
who have performed the glass and flame
n First published in the method of applying a cup may be alarmed
Journal of the Australian and think they have burned the area. This
Association of Massage is not the case. An area that has received a
Therapists, Winter 2015. burn will be red and painful.

18 Vol: 12-2
 feature

mark will be less fierce within 24 hours.

Given a few more days it usually will be
substantially reduced. In most cases, seven
days will see it vanish. Sometimes, especially
if a cup has been applied too strongly, a mark
may last for 10 days or longer. Once a mark
is close to resolution or has disappeared is
an appropriate time to reapply a cup to the
same site.
It is also consistent with healing to note that
when the exact location of a former cupping
session is cupped a second time, the show
of a mark will be usually reduced by at least
40 per cent. Under certain circumstances,
however, cupping marks can continue their
Pic 3: Small red dotting indicates the
form and reappear with little change. Even
release of heat toxins (sha).
when receiving regular weekly treatment,
Temperature diagnostics smokers with toxins constantly being fed
Another striking feature of certain into the body consistently exhibit dark marks
pathogens emancipated and filtered up from after being cupped anywhere in the thoracic
inside to the surface is made apparent by region. So, too, do some athletes who carry
certain definite thermal characteristics that out regular hard exercise without adequate
accompany the release of a cupping vessel. stretching, fluid intake and relaxation.
When coldness is drawn from the body, as the
lip of a cup is released the cupping therapist Six reasons why a cupping
should be alert to the feeling of a draft of mark is not a bruise
coldness escaping and contacting the fingers, The list below is a brief summary of some
like the brief initial blast of cold air felt when of the critical differences between a cupping
opening a freezer door. The skin where the mark and a bruise.
cupping vessel was located will also feel cold. n On many occasions cupping produces
Conversely, when heat is drawn from the no marking, even when a robust volume
body, the therapist can place their open palm of negative pressure (vacuum) is within
above the skin surface and feel the palpable the cup, because pathogens and other
warmth radiating from the treatment site, unwanted factors are not there to be drawn
as is the case after using sliding cupping up to the surface.
and down the erector spinae muscles to treat n By definition, a bruise occurs as a result
women suffering hot flushes. The patient of a blow that does not break the skin
is most likely to also have a very definite (Lackie, 2010), or otherwise, bleeding in
awareness of heat literally pouring out, as soft tissue resulting from a direct blow
it has been described many times in practice. with a blunt instrument (Kent, 2007). The
This release provides great relief. lifting suction effect of a cupping vessel
on the skin stands in stark contrast to the
When to treat next? inward sinking dynamic of a blow to the
Apart from some acute conditions such as surface. Furthermore, there is no trauma
the common cold or influenza, where daily caused by the solid rim of a cup (see Pic 2).
treatment is advised for the first few days, n A bruise changes colour, first to blue as
the ongoing status of a cupping mark is a red pigment of haemoglobin loses its
frequently used to gauge when to repeat a oxygen, and then to brown or yellow as
treatment to the same location. It is vital to the haemoglobin is broken down and
realise that while a cupping mark remains reabsorbed(Kent, 2007). This description
visible, the treatment is still active and in of a bruises colour changes does not apply
progress. Its presence is being maintained by to the fading and resolution of a cupping
the ongoing elimination of the pathogen. mark. The fading of a cupping mark is a
In most cases even a strong coloured dark progressive lessening of the original hue

The Lantern 19
 feature

Bibliography without any different colour transitions. Gaining informed consent

Asnes, R.S. and Wisotsky n When we have a bruise, experience A challenge for practitioners is explaining
D.H. (1981) Cupping lesions tells us that it is tender to touch (due to how cupping works and the possibility that
simulating child abuse. trauma). After cupping there is no such marks may appear. An explanation is best
Journal of Pediatrics, Volume
99, Number 2, The C.V. Mosby
accompanying tenderness. Note: Only when it is easy to comprehend and does not
Co. The United States of following over zealous and aggressive labour the point. Here is a suggestion:
America. cupping can a bruise-associated yellow I think it would be beneficial to do some
Bayfield, Samuel (1823) A stain be produced, together with tenderness cupping for you. Its an ancient method for
Treatise on Practical Cupping. within and beyond the periphery of a relieving sore muscles by promoting blood
Joseph Butler. London. cupping mark. Such a sign represents poor flow and stimulating the release of toxins. It
Bentley, Bruce (2010) Gua practice. is relaxing and comfortable, however it may
Sha: Smoothly scraping out n Imagine a cup has been applied and bring some of those toxins to the surface, which
the Sha. The Lantern 4 (2), 4 produces a strong dark mark. After that will cause temporary marking [its an excellent
-9. Online. Available: www. has resolved and another cup is reapplied idea to have some photos of marks to show].
healthtraditions.com.au on the identical location, with the same They will fade within 24 hours and usually
Bentley, Bruce (2011) Cupping suction level and for the same duration, disappear within three to four days, though in
Deficiency. The Lantern 8 some cases they may linger for a week or two.
the marking is typically only about half
(2), 1527. Online. Available:
www.healthtraditions.com.au
as ferocious as the first time. By the third After checking for any contraindications
session, chances are the response will only and inquiring whether markings could
Bentley, Bruce (2013) Mending
the Fascia with Modern
be a faint showing. Usually by the fourth cause any concern, you can then ask: Are
Cupping. The Lantern 10 (3), treatment no marking occurs. This is you fine to proceed?
4-21. Online. Available: www. clearly a case of an internal pathogen or
healthtraditions.com.au toxin being systematically resolved. This Endnotes
Bentley, Bruce (2014) scenario would be the opposite if it were a 1. Compared to cupping marks, the markings
Cuppings Folk Medical bruise. The capillary damage incurred by a produced by gua sha can be even more dramatic,
less stylized and more difficult to decipher to the
Heritage: people in practice. trauma to produce a bruise would increase untrained eye.
In Cupping Therapy (3rd Ed) with repeated assaults. The following is a
by Ilkay Chirali. Churchill 2. Bayfield (1823) mostly gives instruction about
further illustration. Picture two round wet cupping, with a short section devoted to
Livingstone. China.
cupping marks side by side, with a gap of dry cupping. Wet cupping is when the skin is
Davis, Ruth E. (2000), 2-3 cm between each at the closest point. superficially incised before a cupping vessel is
Cultural Health Care or Child placed over the incision in order to accentuate the
Abuse? The Southeast Asian
When they have faded to half their original
release of blood. It is the safest and least invasive
Practice of Cao Gio. Journal form, apply a single cup over that gap with of all the bloodletting methods. Dry cupping is
of the Academy of Nurse the same level of suction. Strong marking the historical term often used for regular cupping
Practitioners. Volume 12, Issue: will be produced only in the previously performed on an intact skin surface.
3, 89-95. un-cupped space between them. The hue 3. The practitioners manner of applying each cup
formed in the margins of the former cups was also calculated. Rather than alighting each
Eagle, Kim, Manber, Helen
cup on the skin in the usual way, he held each
and Kanzler, Mathew (1996) will a considerably lesser shade. This cup and with a loose downward flick of the wrist
Images in clinical medicine: clearly indicates that the pathogen has literally slapped each one onto the skin. The cup
Consequences of cupping. been resolved to a significant extent within then instantaneously seizes the tissue and strongly
The New England Journal pulls the pathogen to the surface. Additionally, this
the range of the first two cups, compared to
of Medicine, Volume 335, drawing dynamic is further enhanced as the cups
Number 17. the in-between tissue that was unaffected become heated and expand the skin pores and
Kent, Michael (2006) The
by the first application. open a conduit for the body to release unwanted
Oxford Dictionary of Sport, n A bruise can be successfully cleared and unhealthy factors.
Science & Medicine. (3 Ed.) using cupping. Healing a large bruise for 4. The essay Cupping Deficiency highlights to use
Oxford University Press. example, can be accelerated by applying a of the glass and flame cupping method to remove
deep coldness associated with chronic injury and
Published Online: Oxford soft to moderate strength cup to the centre repair flaccid and unhealthy soft-tissue structure.
Reference 2007. Accessed of the bruise and sliding it outwards
1/2/2015. 5. Besides visual and temperature indicators
beyond the bruises perimeter. Complete another intriguing phenomenon occurs when
Lackie, John (2010) A the treatment by repeating the above along sheaths of superficial fascia are tight and a clicking
Dictionary of Biomedicine. successive margins as if following the sound, or a series of clicks, can be heard as a sliding
Oxford University Press. cup moves over the skin. This we can presume
spokes of an imaginary wheel. A bruise
Published Online: Oxford is the sound of pockets of pent-up energy being
Reference 2010. Accessed is after all a form of blood stagnation and released. On every occasion I have heard this, and
1/2/2015. cupping is excellent at dispersing blood in accounts from other practitioners, this audible
stagnation. feedback reflects a successful release of tension.

20 Vol: 12-2