The Philosophical, Cultural, and Historical Aspects of Complementary, Alternative, Unconventional, and Integrative Medicine in the Old World

ALTERNATIVE medicine is the art of offering choices, or several options, that exist and function outside the ordinary medical practice or system of any one country or culture. The styles and methods used are unconventional. Moreover, it is complementary, serving and mutually supplying the lack of therapy that exists elsewhere. It is holistic and attempts to stimulate the body's natural self-healing and self-regulating abilities. It is also favoring integration in a simple and practical pattern.

Alternative medicine was the fundamental method used by humans to preserve their health and avoid diseases since the dawn of time. It is an alternative for those who live far from medical facilities, in places where there are no physicians. Even where there are physicians, people still take the lead in their own health care. Alternative medicine can also be defined as the continuity of traditions, religious beliefs, and even quackery that nonspecialists practice in many ways to treat people. Ordinary people provided with clear and simple information can prevent and treat many common health problems in their homes, which can stop maladies earlier and provide cheaper treatment.

After all, medical knowledge should not be the guarded secret of a select few but should be freely shared by everyone. It is believed by many people that a physician is a helping factor in the cure of the disease rather than the major instrument in healing. The art of healing therefore comes from nature, from God, and not only from the physician. Thus, the physician must start from nature with an open mind and rely on God as the major source of guidance for healing.

Approaching the third millennium, and with the tremendous progress that we witness in the standard of technology and research in different sciences, especially in medicine, people still believe in complementary medicine as safer and cheaper than conventional medicine. It has a great public demand and grows in popularity, especially in the Old World, but even in developed countries like the United States,¹ where it has become increasingly prevalent² and is making a steady incursion into the health budget of Americans. In the United States, for example, unconventional therapy in 1990 generated expenditures estimated upward of $14 billion,³ which doubled by 1997.

Unconventional therapies are medical practices that are not known in teaching programs or in the systems of medical institutions.⁴ These therapies have branched out in the last few years to include categories such as homeopathy, balneology, climatotherapy, chiropractice, acupuncture, and many psychotherapeutic treatments.

A review of alternative medicine through anthropological studies on health problems shows that medical sciences were enhanced by the contribution of some universal figures and scholars who enriched the literature of such civilizations. They did this through translation, copying, collecting, and documentation of all medical material they could retrieve. However, the practice of alternative medicine, especially in the developing countries, needs supervision regarding the use of some products because of the lack of quality control and legislation. Issues of efficacy and safety of complementary medicine have become increasingly important, and supervision of the techniques and procedures is required.⁵ This kind of therapy should also coincide with the ethical criteria of medical practice.

Unconventional medicine came into being early in the history of different Old World civilizations. It is of great significance not only for its intrinsic value but also because it has always been closely allied with other sciences like alchemy, the science of chemistry that has been understood and practiced throughout its long history as a main pillar for such medicine. In addition, it has to do not only with the physical domain of existence but also with the subtle spiritual domain as well.⁶ That type of medicine will continue to have a magicoreligious influence. In the history of Old World civilizations, unconventional medicine was practiced mostly by experts, intelligent and highly skilled individuals. Nowadays there are many people who practice complementary medicine who pretend to cure diseases, but in fact most of them are quacks or charlatans.

Anthropological attention was first drawn to the significance of theories of illness by Forrest E. Clements in 1932.⁷ His research clearly demonstrated that the explanations of illness current among most individuals of the world have little in common with those recognized by modern medical sciences and relate much more closely to the ideology of primitive religion. Studying primitive medicine leads us to the question of the theories of natural causation of illness. These theories are defined as infection, stress, organic deterioration, accident, and overt human aggression. Other theories that partially coincide with our study are the theories of supernatural causation. These are (1) theories of mystical causation that are neither apparent to the senses nor obvious to the intelligence and are mysterious, like personified ill luck or the ascription of illness to astrological influence; (2) theories of animistic causation are related to the existence of spirits that are separable from bodies; and (3) theories of magical causation explain the extraordinary powers over natural forces, incantations, and enchantment.

Medical sciences in general have been brilliantly featured in the different civilizations of the Old World. Many cultures, and in particular the Arabs, have excelled in both the Medieval ages and during the Renaissance (11th Hijri/17th AC) in teaching the medical sciences of Eastern and Arabic origin, which continued to play an important role in Western medical institutions.

The different types of complementary, alternative, unconventional, and integrative medicine in the Old World include the historical, cultural, social, traditional, and philosophical aspects of the various civilizations that prevailed mainly in Asian, African, Far Eastern, Middle Eastern, and Arabian countries. Most of that kind of medicine continues to be practiced today. Many realize that it takes into account not only the individual's physiological and biological conditions but it also includes the psychological, social, environmental, and even spiritual dimensions that may reveal the underlying factors contributing to illness.

Ancient medicine, which was mainly unconventional, was practiced by physicians who were considered to be wise men. An Arabian physician used to be called "Hakim," or "akin," and was thought to have vast experience. He was a profound philosopher, mature, and distinguished for his sound judgment. Such a physician was described (6th Hijri/12th AC) as the following:

The physician should be of tender disposition, and wise nature, excelling in acumen, in keenness and depth of perception, being nimble of mind in forming correct views, and possessed of comprehension that is to say a rapid transition to the unknown from the known. And no physician can be of tender disposition if he fails to recognize the nobility of the human soul, nor of wise nature unless he is acquainted with logic, nor can he excel in acumen unless he is strengthened by God's aid.⁸

Although unconventional medicine was practiced according to the personal judgment and views of the physician, it was still used to reflect the beliefs of that physician. It was controlled by his/her free conscience, mind, and soul. In other words, moral courage in speech and ethical attitudes in practice constituted the philosophy of alternative medical practice and the secret of its success in ancient times.

Today medicine is becoming too divided, compartmentalized, and commercialized, and thus far from its spiritual and pure purport, meaning, and contents. However, at the same time, it was inevitable for medicine to go this way because of the major and rapid changes and progress in the research and technology of medical sciences. It also reflects the economic, social, demographic, and environmental problems that have appeared and recently been recognized in the Old World communities.⁹

Pre-Arabian medicine in the Old World was to our present understanding complementary and unconventional in most of its contexts and practices. Several civilizations that existed in the Old World were characterized by the development in various sciences and in particular medicine.

The Old Egyptian "Pharaohs" medicine is the oldest and goes back to 4500 BC, as documented in papyrus sheets. The Egyptians were the first to perform surgery on the human body. They were also experts in embalming (mummification), using aromatics and herbs to help preserve flesh for thousands of years. They also used the infusion method to extract oils from aromatic plants to create incense, one of the oldest ways of using aromatics.

Aromatherapy began in ancient Egypt, and the medical papyri are believed to date back to 1600 BC and contain remedies for all kinds of diseases. Egyptians used oils of sweet and delicate odor and scent extracted from flowers and pine trees. In addition, they used different types of salts and alabaster to esthetically improve the skin shape. They also produced creams that contain fruit acids (glycolic acid) from sugarcane, mango, apple, and other fruits that were used by women of the royal family and the rich. They also used sour milk, which contains lactic acid, to smoothen the skin. They used many herbs in the treatment of diseases and in particular skin diseases, such as alopecia and skin infections.

The ancient healing art of reflexology was practiced thousands of years ago by Egyptians, Indians, and Chinese. Its premise is that the body has the ability to heal itself. Following illnesses, the body is in a state of imbalance, and consequently vital energy pathways are blocked, preventing the body from functioning effectively. Hence, reflexology can be used to restore and maintain the body's natural equilibrium and encourage healing. Pressure on specific parts of the body could have an anesthetizing effect on the related area. Thus, reflex areas on the feet and hands are linked to other areas and organs of the body within the same zone.

Greek medicine includes a lot of magic and legendary thoughts and practices. The renowned Greek physician Hippocrates wrote his famous oath and invented the theory of body composition paralleling earth's 4 elements: fire, air, water, and soil. He also described the 4 "humors" he believed that the body is composed of: blood, sputum (phlegm), and yellow and black bile. The Greeks used aromatic oils for treating diseases and also for cosmetic purposes. They also used herbal medicine, and the eminent physician Pedacius Dioscorides wrote his herbal medicine book that continues for 1200 years to be a standard Western medical reference on herbs. The Greeks also used hashish to treat glaucoma, and the diluted opium was used as a sedative and painkiller for children.

Persian medicine flourished during the reign of king Shapur I in the city of Jundishapur (near the present Persian city of Ahwaz) in the eighth Hijri/14th AC. Here a school of medicine was founded and considered the most important connection between Arabian and earlier traditional medicine. Persians believed in magicoreligious medicine and the importance of food to health.

Indian medicine was well known for the science of poisons. Indian medicine was based on the theory of the components of the human body by the following 6 balanced materials: blood, flesh, muscles, marrow, mucus, and semen.

Traditional Indian medicine, known as "Ayurveda," which means the science of longevity or "medicine of the gods," was originally a Hindu medical system and had its beginnings in the sixth century. It soon developed outside of the strictly Hindu community and was adapted by Buddhists and other religious groups. It still survives today and is undergoing a renaissance both in India and throughout the Western world. Ayurveda is basically a humoral medical system that maintains that there are 3 essential humors that cause disease if they become imbalanced—wind, bile, and phlegm. One of the main aspects of Ayurveda is aromatic massage. Indians used a lot of herbal medicine, including cannabis for anesthesia and belladonna for pain. One of the most well-known Indian medical books was Wisdom of the Indians, which was translated from Indian to Arabic, then from Arabic to Greek by Simon Antioch in 1070 AC.

Yoga is another kind of worship that is believed to be proceeding directly from God. It is a theological practice that leads to unification with the divine. Yoga is derived from the Sanskrit word "yug," meaning union with the divine. It is the teaching of the suppression of all activity of body, mind, and will so that the self may realize its distinction from them and attain liberation. To the Hindu believers, a yogi becomes beloved by destroying his pride. He gets rid of sorrow if he destroys anger. He acquires peace if he destroys desire. He achieves happiness if he destroys greed.

Urine therapy is also as old as 5000 years and documented in Indian literature. This therapy is based on the simple use of our own water of life: it is the drinking of urine to rejuvenate. The idea is to stop the use of certain medications and start taking a few drops of urine, or rub fresh urine into the acupressure points of the ears. Urine therapy includes external use by massaging or rubbing daily of the whole body for 4 to 8 days. Urine therapy is believed to nourish the body through the skin and regulate heartbeats. Applying fresh urine after shaving produces soft skin. It is also useful in cases of acne, psoriasis, eczema, sunburn, and pruritus. It is effective for athlete's foot, and as compressors for the body and scalp application to help hair growth. Drinking urine, especially the middle stream, is considered a tonic. It is used as gargle for a sore throat and a sedative for toothache. It is useful as an enema, a vaginal douche, eardrop and eyedrop, and also for different diseases.

Chinese medicine started with the philosophy of Confucius who called for the ideal family ties and the promotion of social and ethical standards of societies. Classic Chinese medical cosmology, which is a branch of metaphysics that deals with the nature of the universe, existed through the ages and was naturalistic.

The pattern of Chinese medical practice mainly includes the use of herbs, dietary therapy, massage, and acupuncture. Chinese medicine is a wide subject and is practiced throughout China and East Asia by millions of people.

The Chinese used aromatics at the same time as the Egyptians. Herbal medicine was famous, and Shen Nung's herbal book, dated 2700 BC, is considered the oldest Chinese medical book and contains details on more than 300 plants. The Chinese used aromatic herbs and burned aromatic woods and incense to show respect to God. There are now many traditional Chinese herbs that are used by people for different ailments.

Acupuncture^{10 - 11} is considered to be the most important old and new Chinese alternative medicine worldwide. It dates back as far as 4700 years ago, as it was described by Huang Ti Nei Ching Wen in The Yellow Emperor's Classic of Internal Medicine,¹² considered the most important early Chinese medical book. The most interesting part of this book is the Sun Wên, "Familiar Conversations" between the emperor and his physician Ch'i Pai, because it develops in a lucid and attractive way a theory of humans in health and disease and a theory of medicine.

Acupuncture or "needling" is a method of using fine needles to stimulate the body's own healing process through the body lines of energy. A symptom manifests because the free flow of this energy is obstructed. Consequently, the aim of acupuncture is to remove these obstructions and to encourage the energy to flow smoothly. The Chinese believe that each symptom is only the end product of a series of breakdowns in the proper functioning of the body and mind. Each symptom has a route cause, which has a deeper route cause and so on until one gets back to what is termed the constitutional factor. In Chinese medicine each organ has responsibility for maintaining specific aspects of physical and emotional health. The acupuncture point is a precise anatomical location where the energy can be contacted by inserting a needle. Acupuncture works through the following 5 theories:

Moxibustion or moxa has a similar purpose as acupuncture. It is the ignipuncture that is based on heat and is highly recommended to treat many diseases. The practice is almost analogous to cupping, which is still used in the Old and New Worlds. It produces stimulation of key nodal points along the circulation tracts.

Acupressure was also invented by the Chinese, which is the stimulation performed with fingers rather than needles. It is based on the principles of acupuncture.

Feng shui¹³ is the ancient Chinese study of the movement of invisible energy, or chi, which is founded on wisdom. It has been practiced for thousands of years and concerns how the environment in which we live and work has an effect on our physical, mental, emotional, and spiritual well-being. The philosophy of feng shui is that to change people's way of living they have to change their homes, which includes design, color, art, and different arrangements that will affect the movement of energy in the home, such as bedrooms, halls, stairs, kitchen, bathrooms, and workplaces. It also includes changes in schools and gardens. Such changes will eventually be reflected on health and create opportunities and happiness that can result in feelings of satisfaction and peace.

The "Bagua" is an ancient form of map that shows how energy moves within a defined space. It is a template divided into 9 areas that can be laid over a plan of a land, a house, an apartment, or rooms. It gives clues to how we can create new possibilities in our lives. The map is divided into the following 9 areas with a definition and meaning for each: (1) water/journey, (2) earth/relationships, (3) thunder/elders, (4) wind/fortunate blessings, (5) health (Tai Chi)/the center of all areas, (6) heaven/helpful friends, (7) lake/creativity, (8) mountain/wisdom, and (9) fire/illumination.

The feng shui philosophy could change people's environments if it is done gradually with the use of one's own energy. Our diets, exercises, lifestyles, personalities, and astrological profiles are all important in producing the environmental change and the positive reflections on our health that is the main goal of that philosophy.

The goal of feng shui is a healthy and harmonious lifestyle. The study of the movement of energy forms the basis of one of the most noted analytical systems in Chinese Culture—Wu Hsing. Wu Hsing means the 5 elements or 5 energies and is based on the theory that energy tends to move in 5 directions, ie, radiating outward, concentrating inward, rising, descending, and rotating. In the system of the 5 energies, different colors, smells, and tastes are seen as manifestations of each of these energies and so are the seasons, foods, directions, and numbers. The 5 energies are described using the names of 5 natural phenomena that typify those movements of energy: fire, earth, metal or gold, water, and wood. They control each other through a relationship known as the central cycle.¹⁴ Every organ in our body is classified under the 5 elements, which represent material forces that were introduced by the Chinese as early as the fourth century BC—gold (jin), wood (mu), water (tu), and earth and fire (hua). Gold has the nature of quietness, wood is the evidence of growth, water is coolness, fire is heat, and earth has the quality of substance. The 5 elements¹⁵ or energies may combine, change with seasons, and have different colors, shapes, directions, and locations.

The health of the human being is the main core of energy in our body. Every organ in our body is classified and influenced by the 5 elements (Table 1). Thus, the wood element will create liver and eye diseases, the fire will create heart and tongue diseases and so on. The philosophy of feng shui is still practiced by millions as an alternative medicine.

Chinese dietary therapy is based on the theory that "we are what we eat," and what we eat is important to our health and could cause illness.

Kinesiology is another practice in Chinese medicine, which is the study of the principles of mechanics and anatomy in relation to human movement. It is practiced by training that enables patients to control their biological processes.

Moreover, Chinese medicine is a holistic type of medicine. It treats the individual and reflects the unique experience of that disease. It also treats the vital energy and encourages the body, mind, and spirit to return to a harmoniously balanced state of well-being.

Romans took much of their medical knowledge from the Greeks. They used and improved the effect of aromatics and they also used steam, sauna, and vapor baths, and Rome became the bathing capital of the world. Using oils and massage was a continuous practice of the Romans.

They also imported herbs and aromatic products from India and Arabia through the opening up of trade routes. The Romans used to cauterize the wounds and ulcers of the cervix. They also performed the cesarean section.

The prolonged wars between the Romans and Persian empires led to disasters and ethnic tensions among Greeks, Semites, Persians, Armenians, and Slavs with splits among Christian groups. The bubonic plague in 541 AC heralded 200 years of outbreaks. The efforts of Justinian (524-565 AC) to recover the Roman Empire did not work, and the Greeks also became weak. Learned medicine continued in large cities and in particular in Alexandria, but physicians were not so popular, and religion dominated the life of people in that era. At that time the scene was set for Islam, when Mohammed the Prophet (570-632 AC) came from the Quraysh tribe that ruled Mecca,¹⁶ and at the age of 40 years he received God's call, and the Holy Quran (Koran) was revealed to him in visions. By the time of his death, all of Arabia had been won over to Islam, and a century later his followers had conquered half of Byzantine Asia, all of Persia, Egypt, the Maghreb (North Africa), and Spain. Islam was not a proselytizing faith and did not force people to convert. Islam granted Christians and Jews special status as "People of the Book" (Anl-al-Kitab). During the Arab-Islamic empire medicine flourished because it was promoted by Caliphs, and Baghdad, Seville, Toledo, Granada, and other cities were well known as main centers for Arab-Islamic medical sciences and culture.

Unconventional medicine in ancient Arab-Islamic civilization was characterized as metaphysical and was also sometimes gnostic, practiced by those who believed in gnosticism. It was supernatural, abstruse, and marked by unconventional imagery. It was popular, inexpensive, widely accepted, commonly liked, and approved. It related to the general public, was easy to understand, and suited the means of the majority. It was not coincidental to have a good number of universal outstanding figures of Arab-Islamic scientists who played a major role and contributed to both traditional and unconventional medicine and who were philosophers at the same time. Such a physician usually was a poet, writer, historian, mathematician, chemist, astronomer, and, above all, philosopher. He was known as the "Hakim," or "sage," who reflects the unity of the sciences as many branches of a tree whose trunk is the wisdom embodied in the sage.

Arabian physicians stressed that treating the early symptoms of a disease by unconventional means, especially herbs, will not mask the disease but expose it in the early treatable stage. They also believed in preventive medical practices such as diet, exercises, hygiene, and moderation in habits. It is of interest to remember an old saying: "A good physician tries to keep people in good health and good shape, but a lesser physician will only treat people when they get sick."

Medicine in general is considered to be one of the most illustrious and best known facets of Arab-Islamic civilization in which Arabs most excelled. It became influential in Western medical circles to such an extent that it was included in the curriculum of medical schools for many centuries. Arabic medicine was a result of Roman, Greek, Persian, and Indian theories and practices, within the general context of Islam's system of ethics. Islam was based on revelation, with its simple meaning as "submission," and "peace," or "being at one with the Divine Will." Arabic medicine was connected to philosophy and tied to numerical and astrological symbolism and influenced by magicoreligious thoughts. Arabs then established and promoted their own medical sciences in theories and practices that became highly influential in Western science and teaching.

Physicians, whether they were Muslims, Christians, or Jews, under the umbrella of Islam raised the dignity and caliber of the medical profession. The teaching in the light of edicts from the Holy Quran and prophetic directions led the scholars of mysticism and spiritualism to the determination between the material and the spiritual worlds. The teaching of the Holy Quran is also the belief in Allah (God) and the Day of Judgment after life. Faith exercises a deep effect on the spirit and the body of humans. Muslims believe that diseases are the result of the dissociation of the harmony between the body and the spirit, and faith is the exactitude that is extremely effective in keeping the harmony intact through its belief in "tawhid" (unity) of thought; thus, healing comes through faith.

During the Islamic age, Arabs raised the dignity of the medical sciences from that of a menial calling to the rank of one of the learned professions.

I mention herein some of the unconventional medical practices that were present before and during Islam, and many of them are still practiced today.

Physiognomy is the ability of discovering temperament and inner characters of an individual from the outward appearance. Arabs believed that a disease would attack a person or a tribe due to an evil, which can also cause harm to certain people or a tribe. This evil can be driven away by the use of charms and magic. Those practicing physiognomy also used magic to intimidate their enemies.

This type of medicine is clerical or ministerial and invisible. It was a priestly medicine practiced by clergymen, wizards, and sorcerers who were skilled in magic. Such individuals could influence the mental and physical states of others by foretelling their health condition.

A fortune-teller is one who professes to foretell the future and claims that by looking at and talking to an individual could tell secrets of the past, present, and future of that person. He/she also predicts knowledge about health, wealth, and destiny and fate. A diviner, or augurer, can also use cards arranged in different ways and to tell secrets and a person's fortune. The fortune-teller might use a cup from which a person has drunk coffee, let the cup dry for a few minutes, and then read the lines, streaks, and what shows as figures and pictures made by the remnants of coffee at the bottom and inner sides of the cup to tell the person's fortune. This reading is based on intuition, anticipation, and foreknowledge.

Geomancy is the art of using sand or small pieces of stones of different shapes to tell the fortune of a person. The individual who practices geomancy tosses stones or cowrie shells and interprets the arrangements to predict the future.

Palmistry is practiced by the chiromancer or palmist who looks at the different markings, lines, and ridges on the palm of a person to foretell his/her future, health, the length of life, and destiny.

Exorcism is practiced by magicians, prestidigitators, sorcerers, quacks, and charlatans to drive away bad spirits and evil from the soul and body in states of illness or catastrophies. People believed that the forces responsible for ill health were the evil spirits that transmigrate into the body by the process of metempsychosis. Many still believe in "jinn" and the evil eye (al'ayn), a glance that is supposed to harm those on whom it falls. The jinn (plural, jinni) could bring good as well as bad luck. They were to blame for fevers, madness, and children's diseases. Spiritual therapy is practiced in many Arabian countries and is based on the exorcism and expulsion of bad spirits from the body.

Inspiration is a divine influence or action put on a person to make him/her, by suggestion, believe an idea and produce an effect on him/her with that idea. Burying a green wedge in a cave in the dark during the night, inserting a gram of wheat in an eggplant and then touching a wart with it are some of the methods used. After the green wedge or eggplant is buried and forgotten, warts are believed to have been cured.

Amulets are prescribed, prepared, and advised by certain clergymen or magicians or sometimes ordinary people who claim to possess the knowledge of the secrets of amulets. Amulets or periapts are usually made of different kinds of cloth, often silk or cotton, with different colors and in different shapes. They usually include a piece of paper with written incantations, either religious phrases or words that can work as exorcism of evil. Some amulets also contain pieces of hair from a man or his wife. They might also contain nonsense words or nothing.

The people who carry amulets believe and are told to believe that amulets are useful to bring good luck and health to them. Sometimes they are meant also to beat somebody or intimidate an enemy or make sterile women conceive. Amulets are hung around the neck or placed near the chest, abdomen, umbilicus, or pubic region and genitalia. They are also placed under the main steps of the house or bedroom or under the pillow or bed.

Arabs believed in the healing power of gemstones, metals, and crystals. They are useful for protection of the body and soul, and drive away sickness and vanquish enemies. Each stone has its value and effect according to its size, shape, and color.

Astrologists claim that they can read and understand the meanings behind the appearance, disappearance, and movements of certain stars. They also relate all that to the beginning of an epidemic of a disease, a disaster, or misery or happiness of a person or a tribe. Counting stars is also believed to cure some diseases such as warts.

The horoscope is the diagram or map of the relative positions of planets and signs of the zodiac at a specific time. It is used by astronomers to infer individual character and personality traits and in foretelling events of a person's life as at one's birthday. This is known as astrological forecast.

Horoscopes can denote revenge, grudge, hostility, dissatisfaction, indignation, optimism, pessimism, confidence, expectation, travel, and wealth. They can tell the existence of a love affair or enemies and health status and length of life. Some people shape their lives and behave on a daily basis according to their horoscopes. They might get scared if they expect a bad event and become sick and paranoid. Good news, good luck, feeling down, and the feeling that people we consider as close friends have abandoned us are some interpretations. They might also have a funny side, known as cosmic laugh.

Cupping is still used to treat chest infections, and in particular pneumonia and muscular pain. It is a procedure in which blood is drawn to the surface of the skin by the use of a glass vessel evacuated of air by heat. A small piece of paper is burned, placed inside glass cups, and then extinguished, so that the air inside the cups will be burned and emptied. The cups are then placed on areas such as the chest, back, buttocks, chin, and dorsum of the foot. The cups are left on a specific area for a few minutes, and eventually they will stick by negative pressure to the skin. Next they are removed, leaving raised red patches, which are rich in blood supply with the production of superficial skin inflammation that will help to reduce inflammation in deeper adjacent organs. Following that, both pain and infection will be alleviated by the effect of counterirritation.

Arabs believed that cupping could be useful to treat 72 diseases, including leprosy, toothaches, boils, gout, piles, and elephantiasis.

This method is still used to treat some kinds of pain, alopecia, and warts. Cautery with fire by using a burnt stick and/or lighted cigarette are used to treat warts. Garlic and vinegar are used to rub an area of alopecia areata to stimulate hair growth. Garlic is rubbed and vinegar is applied to smoothen stings of bites. Cautery to the back and at certain specific sites is well known to treat sciatica and lumbago pain.

Scarification is made by scratching or making incisions in the skin using a razor blade or knife for bloodletting. It is based on the assumption that this will get rid of poisoned blood. Scarification is practiced for snakebite, in which the limb is cuffed and fastened tight by a rope or a piece of cloth above the site of the bite to prevent the poisoned circulating blood from moving upward. The bitten area is then scarified and incised for bloodletting. Sometimes the blood is sucked and spit out. The site of the bite is then covered with a poultice.

Leeches are used to suck blood from the ears, face, neck, thighs, or legs. They are still used mainly by barbers who place the leech on the surface of the skin and leave it for 15 to 30 minutes while it sucks blood, becomes swollen, and then drops off by itself. This kind of therapy is used to reduce hypertension, relieve headache, and treat varicose veins in the lower limbs.

Compresses and poultices are used for different purposes in treating many illnesses. A piece of cloth is immersed in cold water and then squeezed, or some ice is wrapped with the cloth, which is then applied to the forehead, hands, forearms, thighs, and legs to reduce body temperature. Poultices are made of a mixture of herbs in a paste form such as mustard papers, cayenne, and ginger oils, then applied to the area of pain for 1 to 3 hours. The idea is to increase blood circulation in the treated area and create a counterirritation. Poultices are sometimes made of cabbage or warm bread, in which a warm piece of bread is applied to sties on eyelids to help them drain.

This therapy is a process in which steam from a bowl of boiling water is allowed to seep into the face or any area of the skin. It is applied for 5 to 10 minutes, and an essential oil, a menthol, or incense is added to the boiling water. The top of the head and sides of the face are covered with a towel to prevent evaporation. Vaporization is useful for colds, flu, acne lesions, and as a freshener too.

Phlebotomy was also practiced by Arabs to treat many diseases in the belief that drawing and letting blood will get rid of the excess contaminated blood. It was usually done using a heated knife, razor blade, or a warmed needle. It was useful in the treatment of headache, hypertension, and many other conditions.

A puncture in the abdomen was created by Arabs using a knife sterilized by fire. This procedure was used to treat ascites, which Arabs believed to be due to bad water in the abdomen.

Arabs used many kinds of herbs to treat different diseases, and even now herbal medicine is still popular and practiced by some physicians, but also by many quacks. Arabian herbal medicine was famous and Arabian scientists wrote many books describing the uses, indications, and benefits of such herbs.^{17 - 18} There are some important books and manuscripts in the Arab herbal pharmacopeia. The most renowned ones are the following:

Examples of some herbs and fruits that were used by Arabian scientists and are still used in the European pharmacopeia are Myrtus communis L (myrtle), Asarum europaeum (assarbacca), Papaver somniferum (opium), Pimpinella anisum (anise), and Matricaria chamomilla (wild chamomile).

The following are some examples of Arabian herbs, their Latin names, and uses: Gelsenium sumpervirens (yellow jasmine) for migraine; Apium graveolens (celery) for gout; Angelica archangelica (angelique) for rheumatism; Alliam sativum (garlic) for flu and influenza; Forsythia suspensa (lian qiao) for abcesses and folliculitis; Morus alba (mulberry) for cough; Pimpinella anisum (anise) for cough; Galium aparine (cleavers) for psoriasis; Aloe vera (aloe) for vitiligo and fungus infection; Plantaso psyllium (psyllium) for constipation; Agrimonia eupatoma (agrinomy) for diarrhea; and Trigonella foenum-graecum (fenugreek) for diabetes mellitus. Wallflower (gilly flower) leaves are crushed and mixed with salt for treating eczema. Nigella sativa mixed with olive oil is a good local moisturizer for ichthyosis and psoriasis.²⁰

Polypodium leucotomos "difur" is an herb that contains a lipid hydrosoluble extract known as "calagula" or "anapsos."²¹ The leaves of this herb were used first in Spain and Portugal to treat psoriasis and then vitiligo,²² as they proved to make psoriatic²³ lesions disappear, and to repigment vitiliginous skin. The leaves are grounded or made into a paste and applied to the vitiliginous lesions and the areas are then exposed to sunlight. The herb was also used to treat eczema.

Aloe is a large genus of succulent, chiefly southern African plants of the lily family with basal leaves and spicate flowers. The dried juice or the leaves of various aloes are used as a purgative and tonics. The extract is also used as a 0.5% hydrophilic cream with or without salicylic acid to treat psoriasis. It is also used with exposure to sunlight to treat vitiligo. Aloe is believed to regenerate capillaries and promotes regrowth of hair follicles.

Psoralens as repigmenting agents for vitiligo were described as early as 1400 BC. The Indian sacred book Atharva Veda mentioned the effect of the plant on the skin color. Ancient Egyptians identified Psoralea corylifolia and Amni majus as psoralen, and they used it for vitiligo. Psoralens are furocoumarin compounds, photodynamically active drugs that are capable of absorbing radiant energy. They are also found in limes, lemons, celery, figs, and parsnips. Psoralens²⁴ were introduced into the field of dermatology by El-Mofty^{25 - 26} in 1947 when he observed repigmentation of vitiliginous lesions after the use of powdered seeds prescribed by herbalists. The drug was then manufactured in both a lotion and tablet form as meladinine.

Khellin is produced from the seeds of the plant Ammi visnaga, and its chemical structure closely resembles that of psoralen,²⁷ used as a topical application in combination with sunlight for vitiligo.²⁸

Tattooing is used in the Arab world as a decorative and cosmetic practice on the face and the back of hands for women, and is also a tribal tradition for men.

Henna is an Old World tropical shrub or small tree (Lowsonia inermis) of the loose strife family with small opposite leaves and axillary panicles of fragrant white flowers. A reddish brown or blackish dye is obtained from the leaves of the henna plants, especially in the Arab world. The powder of henna is used by women to dye hair, and used also in marriage ceremonies by painting different shapes and figures on hands and feet of women and children. Some men are using henna to dye scalp, mustache, and beard hair. Henna is also applied to the hands and feet to treat some skin diseases or as a camouflage for vitiligo and skin scars.

Kohl is a black powder that is used widely in the Arab countries. It is used as a powder or smear to darken the edges of the eyelids similar to eyeliner. It was introduced to Europe in the 13th century by Crusaders who brought kohl from Arabia as presents to their wives and girlfriends, and is still used today. Some men from certain tribes in Arabia also use kohl as eyeliner. It is also used as a treatment for blepharitis.

The Arabs used honey as a medicine for many centuries to improve the blood circulation. It is also a laxative and relieves stomach pain. It is a protective agent for children against scurvy and rickets. Honey improves hearing and vision. It is used as an antimicrobial and antifungal in the form of creams or liquids in 10% to 50% dilutions. It is used as warm eardrops when mixed with salt to clear earwax and infection. It is used as a mouth gargle for tonsillitis and diphtheria. Honey is also mixed with hot lemon and used to ease colds and congestion. When applied to the skin it clears infections, abscesses, ulcers, and folliculitis. It has also been used to treat lice in children.

Oral contraceptive methods²⁹ included drinking water of sweet basil or weeping willow leaves, eating beans on an empty stomach, dogs fennel in "white drink," and consuming myrrh and cinnamon after menstruation. Contraception was also performed by magical means such as stepping on the cyclamen plant or the use of suppositories and tampons, such as tar, before and after coitus. Flowers and seeds of cabbage, after menses, are also used before or after coitus. Pulp of colocynth, white bryony, iron dross, sulfur, scammony, and cabbage seeds with tar are also well-known methods of contraception.

Abortifacient methods include techniques used by men such as onion juice smeared on the penis, or smeared tar or balm oil and white lead on the penis before coitus. Other miscellaneous techniques include smearing the navel with the gallbladder of a cow plus a recipe taken orally and by insertion in the vagina. Fumigation with galbanum plant and sulfur and savin is also a time-honored method as well as avoiding simultaneous orgasms. Bodily movements and jumping backward to expel semen, spoiling the testicles with hemlock, sitting in the broth of wallflowers and Jew's mallow green sticks are still used, especially in Egypt, and introduced into the cervix and manipulated to help induce abortion.

Chiropractic medicine is a system of therapy that considers that disease results from a lack of normal nerve function and uses manipulation and specific adjustment of body structures, such as bones, joints, and spinal column. It is a health care discipline that emphasizes the inherent and restorative power of the body to heal itself without the use of drugs or surgery.

It is still practiced widely in the Arab world by chiropractors who are not physicians. Even today, chiropractors use observation and knowledge and their vast experience to identify the cause of pain, whether it is a bone fracture or a joint or a spinal column problem. They usually use pieces of wooden board to splint the fracture. For example, if it is an arm fracture, a chiropractor applies an ordinary cloth bandage underneath and over the arm, then a paste made of a mixture of egg white with ground homemade soap is applied all around the fractured limb that will stick the cloth to the splint, and then the limb is hung 2 to 3 months before it is released. In a case of a badly healed fracture, the chiropractor would wrap the broken limb with a piece of cloth to protect it from burns, and then the limb is exposed to the vapor of a boiling Inula viscosa herb. After a few minutes there is a dramatic response, and the badly healed fractured bone releases itself and the fractured parts separate. After that, the chiropractor unites them again as previously described.

Fasting is 1 of the 5 basic elements of Islam. It is considered one of the means of providing the ideal conditions necessary for the repair of bodily damages and for the elimination of toxins. It is an exercise in which a Muslim purifies the body and soul by feeling hunger and thus sympathizing with those who are hungry because they cannot afford to buy food. Fasting during Ramadan every year includes meditation, contemplation, and cogitation.

Male Circumcision. This is both a Muslim and a Jewish rite performed on male infants as a sign of inclusion in the Muslim or Jewish communities. It is usually practiced in most countries of the Old World by barbers and includes a quick cut of the foreskin (prepuce) with a sharp knife or a razor blade. It is also practiced by Arab Christians on the basis of natural hygiene.

Female Circumcision (Clitorodectomy). This is an ancient practice³⁰ performed in the name of tradition without ideological or religious sanction.^{31 - 32} Evidence from the remains of female mummies dating back to 2000 BC indicates that female genital mutilation originated during the reign of the Pharaohs. Ancient Egyptian myths stressed the bisexuality of the gods, and thus circumcision may have been introduced to clarify the femininity of girls. In some African countries the clitoris is considered a masculine organ that should be removed. Circumcision is practiced in about 30 African countries that include millions of Arabs from Mauritania and the Ivory Coast in the west to Egypt, Sudan, Somalia, and Tanzania in the east. The Arabic name for circumcision is "tahara," which means "to purify." It is practiced by Africans of all religions, Muslims, Christians, and Ethiopian Jews, as well as followers of animist religions, such as the Masai.

Recent statistics from the World Health Organization show that more than 100 million women have undergone circumcision in about 40 African countries. In Egypt, almost 80% of rural women are circumcised and around 370 girls are operated on daily. Ninety percent of circumcisions are performed by traditional practitioners, mainly barbers and sometimes midwives.

The justification of clitorodectomy is based on the belief of sexual control of women and the prevention of female promiscuity. It is believed that circumcision will abolish women's sexual enjoyment, and that clitoris cutting is closely associated with virginity. The operation lasts 15 minutes, during which the girl is nude and her legs spread wide apart while she is held down by several women. A traditional practitioner offers a short prayer, takes a sharp razor, and excises the clitoris. The razor cuts from top to bottom, which often cuts part of labia minora of the vagina. Then the practitioner uses 4 acacia thorns that pierce one side and pass through the other held in place by a thread or horsehair to close the wound.

The procedure is painful and horrifying for the girl and has complications that include sudden death from bleeding or tetanus resulting from the use of unsterilized equipment such as razor blades, iron knives, and broken bottles. The child might develop severe and permanent scarring that eventually leads to difficulty in urination and menstruation. The mutilated scar might cause future fetal and maternal death when the girl marries and becomes pregnant. It also creates a psychological trauma for the victim. Other complications include recurrent infections, pain during intercourse, infertility, and spreading of the acquired immunodeficiency syndrome.

Infibulation is another type of circumcision in which the clitoris and labia minora are cut, and then the labia majora are stitched together to cover the urethral and vaginal entrances. This is practiced in Sudan, Mali, Somalia, Ethiopia, and Nigeria.

The practice of female circumcision has been recently considered torture and a form of genital mutilation. It has nothing to do with religion or morality. Governments in most African countries especially in Egypt have recently banned such practice but are faced with objections, and at least are trying to subject such procedures to medical supervision. Immigrants from African countries to the United States and Canada brought the practice of circumcision with them. Female circumcision was criminalized by the US Congress and some state governments.

Water has always been an important topic in medicine.³³ It has been prescribed for the treatment of edema, arthritis, psoriasis, and even sexually transmitted diseases. In contemporary practice, water is used for compressing, bathing, and cleansing the skin. One of the various uses of water in alternative medical practice is in balneology.

The study of the medicinal uses of mineral water and the uses of water has been an integral part of human existence. Water is a natural gift and is a part of the act of purification found in the major religions. The Pharaohs, the Greeks, and the Romans developed medicinal and religious rites associated with water.^{34 - 35} The Pharaohs worshiped the Nile River³⁶ because they believed it to have supernatural powers and the ability to cure diseases. The Ganges River has significance in the Hindu religion, just as the Jordan River has importance to Christianity and Judaism. Muslims and Buddhists relate washing to religious purity. Muslims believe in the performance of rituals or ablutions by washing 5 times a day before each of the daily prayers. The Hindu believes that Ganges water brings physical wellness and peace. The healing aspects of the Dead Sea water were known for ages and mentioned in both the Old Testament and Holy Quran (also discussed in the "Climatotherapy" section). Water from the Zamzam well in Mecca is considered holy, and millions of Muslim believers use it to cure diseases.

The effects of warm spas are activation of sweat glands, dilation of cutaneous blood vessels, and stimulation of intestinal peristalsis.³⁷ They have also vagotonic action and augment blood pH levels.

Thermal and mineral waters are also used as alternative therapy in many countries in the Old World. There are many health spas and clinics around the world offering a wide range of natural treatments that may be combined with a relaxing vacation. Many of these centers are used simply for restoring health. European countries have a 2000-year tradition of spa treatment. The former Soviet Union alone has 3500 spas.

Thermal and mineral waters are present in the Middle East, in particular in Jordan and Israel. Such waters are considered curative due to their physical and chemical properties and also through psychological effect.

Thermal and mineral spas are believed to help relax muscles and the mind, provide relief of muscular and joint pains, respiration, and heal infections. Water containing hydrogen, sulfur, carbon dioxide, and bromides is useful as a tranquilizer and a relaxant. Some waters are radioactive and contain high levels of iodides, iron, calcium, and magnesium, and are useful for the body as a whole. It is believed that mineral water exerts an effect on the immunological and neuropeptidergic systems of the skin beyond the antibacterial, antifungal, and keratolytic effects.³⁸ Water plays an important role in dermatological therapy through its hydrating, cooling, and cleansing effects, and as a vehicle for more effective delivery of active agents.³⁹

The use of sunlight in the treatment of different diseases was known for many decades even before advanced technology in this field, in the form of phototherapy and photochemotherapy (psoralen–UV-A), were introduced.⁴⁰ Heliotherapy was used especially in Europe to derive benefit from the UV-A present in sunlight to treat numerous diseases. Many sanitariums were established for sunbathing to treat diseases of the chest and in particular tuberculosis and rheumatism, in addition to various skin diseases.⁴¹ Heliotherapy is an alternative therapy for patients with skin diseases, especially psoriasis, so that the severity of the disease is dramatically reduced and they receive favorable long-term effects.

Exposure to sunlight to treat different ailments and skin conditions and the use of natural health spas and mud have been used for thousands of years to treat psoriasis and other diseases.^{42 - 43} Skin shows marked improvement in many cases with a longer delay of relapses, less need to use conventional medications such as corticosteroids, and eventually fewer adverse effects. These were also a much less expensive method of treatment.

The Dead Sea is one of the most popular sites for climatotherapy. It is the lowest point on Earth, 400 m below sea level, and it is the world's saltiest lake, with salinity reaching 290 g/L,⁴⁴ compared with that of the Red Sea, whose salinity is only 40 g/L. The natural elements and minerals in the sea, in addition to the mud present on the shores, give the water their curative powers, as has been mentioned in the Bible and recognized by king Herod more than 2000 years ago. However, the principal factor in the cure of skin diseases, mainly psoriasis, comes from the naturally filtered UV radiation, which is greater in UV-A and low in UV-B compared with other locations⁴⁴ ; this permits a prolonged exposure to sunlight with minimal phototoxicity. This filtered UV radiation is due to the thick atmospheric layer over the Dead Sea, with its vapor and haze, and to the great amount of ozone, which is minimally depleted compared with other areas. It is also due to the low humidity and warm climate, with 332 sunny days yearly in that area.⁴⁵

The Dead Sea Spa Treatment Centres in Israel (Ein Bokek) were established years ago and have attracted thousands of patients, mainly from the Netherlands, France, Switzerland, Italy, Austria, Germany, the United Kingdom, Scandinavia, South Africa, and the United States, in addition to patients coming from within Israel.^{46 - 47} Most of those patients seek therapy for psoriasis.

The Dead Sea Spa Treatment Village in Jordan was opened in 1991 and since then thousands of patients with psoriasis, mainly psoriasis vulgaris, and other diseases such as eczema,⁴⁸ acne, and asthma have received climatotherapy at the village, which is 35 km west of Amman, the capital of Jordan. Most patients are from western Europe, Arabia, and Jordan.

It is anticipated that the peace process between Jordan and Israel will create active cooperation, promote bilateral and regional studies, encourage research, and eventually promote health tourism in many areas, such as wellness health centers, especially in the Dead Sea region.

The Dead Sea is mentioned in the Old Testament and Holy Quran, and it was described by both the Greeks and Arabs and was given many names, including Sedom, Dragon, Araba, Asphilt Sea, and Lot Sea⁴⁹ (Lot, ie, the nephew of Abraham, who lived at Sodom and Gomorrah).

The Dead Sea water contains a natural tar called bitumen, which is why it has been called the Asphilt or tar sea. This natural tar is believed to function as an anti-inflammatory and keratolytic agent to the skin. In general, it is possible that the water of the Dead Sea functions as a major factor in slowing down the rapid turnover process of skin cells in patients with psoriasis, a possibility that should be further investigated.

The mud at the Dead Sea is rich in magnesium, natural tar (bitumen), and silicates (silicon compounds); the latter is often used as a mask for the skin.⁵⁰ The black color of mud absorbs much of the solar radiation, hence acting as a photosensitizer when applied to the skin. Mud baths are useful mainly for arthropathy because they aid in stimulating blood circulation around the affected joints; thus, mud packs are effective for individuals with psoriatic arthropathy.

In conclusion, the curative alternative factors at the Dead Sea are climate, sunlight, water, and black mud, along with their physical and psychological effects.

The most popular kind of unconventional medicine is naturopathic medicine, which is a natural approach to health and healing that recognizes the integrity of the whole person. The philosophy of naturopathic medicine includes the treatment of disease through the stimulation, enhancement, and support of the inherent healing capacity of the person. There are 6 principles for this kind of medicine: (1) the healing power of nature—the body has the inherent ability to establish, maintain, and restore health; (2) identify and treat the cause—underlying causes of a disease must be discovered and removed; symptoms are not the cause of a disease, and the causes of diseases include physical, mental, emotional, and spiritual factors, which all have to be dealt with; (3) first do no harm—therapeutic action should be complementary to and synergistic with the healing process; (4) treat the whole person; (5) the physician as teacher—he/she should create a healthy interpersonal physician-patient relationship; and (6) prevention—it is the aim of the physician, and the best cure; it is the building of health rather than fighting the disease.

Hypothermia is the use of cooling with direct ice or ice packs to treat bruises, swelling, joint problems, and muscular pain. It is also useful to lower the body temperature. It was first used as an anesthesia in World War I by surgeons to amputate injured limbs or operate on injured extremities.

The effects of cold include stimulation of vegetative sympathetic nervous system (sympathiotonic action), dilution of the blood, diminution of blood pH, and diminution of intestinal peristalsis.

Hyperthermia is the use of heat to treat certain skin diseases. It was used as direct cautery for many centuries to treat backache, infected skin conditions, and leishmaniasis pimples. It is also used now to treat warts. Cautery was used to seal the stumps of amputees involved in wars.

Hypnosis is defined as an unusual or altered state of consciousness in which distortion of perception occurs as uncritical responses of the subject to motions from an objective source, a subjective source or both.⁵¹ Hypnosis is mainly used to treat obsession, fear, anxiety, and other psychological and emotional disturbances. It is also used to discover events and incidents that happened to the patient that he/she had forgotten or occurred to others such as crimes that they witnessed.

Homeopathy⁵² is a system of medicine based on the theory of "like cures like." For example, a poison that causes symptoms of illness in a healthy person can treat the same symptoms in a diluted form. Substances are diluted several times to make a remedy that is safe to use, yet homeopaths believe sufficient likeness remains between the remedy and the illness to stimulate the body's self-healing abilities. It is based on the pharmacological "law of similars" that was invented in 1796 by Samuel Hahnemann, a German physician. The word derives from the Greek "homoios" and "pathos," meaning to suffer. Another example is rubbing chilblains with snow. Homeopathy also encourages people to reject strong medications.

The philosophy of diamond, crystals, and precious stones therapy is based on the belief of using energies in the healing of a disease, trauma, or an injury. It is holistic, and many claim benefits from this kind of therapy. The healing properties of gemstones, minerals, and crystals were common and used for many centuries to treat many diseases. They have different philosophical evaluation and variant effects on people. The quality, shape, and color of the gemstones are also important in their effect. Some people feel more self-confident when they wear certain stones such as amazonite. The wearing of a purple necklace is spiritual and placing it on the abdomen might cure intestinal problems. The rose quartz and the aquamarine have much to do with the mood of love. Cape amethyst, for example, was believed to be useful for arthritis when strands were wrapped around the joint. Carnelian was used to treat allergic reactions and asthma. Coral, diamond, emerald, and green and purple fluorite are used for emotional stress and hormonal imbalance, and jade for relaxation. People select precious stones according to their birthdates and they are classified according to their horoscopes. Garnet for January means fire elements or energy, and represents drive in life. Amethyst for February means fine, peaceful, intelligence, comfort, kindness, and honesty. Diamonds for April as gold, everyone's best friends and represent eternal love as the most hardest and brilliant stones. Pearls for June and rubies for July symbolizes feminine charm and love. Topaz for November represents friendship, and it has the power to improve eyesight and mental perception.

Massage was used thousands of years ago by the Chinese. It was preventive, practiced on healthy individuals and not the ill. The Japanese massage called "shiatsu" was recommended for those living in the highly cultured areas in central Japan, near the Yellow River where people had more mental than physical stress. The Japanese shiatsu is finger pressure applied to specific points on the body. The word massage comes from an Arabic word meaning "stroke." It dates back 3000 years when it was practiced in China, then later by the Arabs. Massage is the manipulation of tissues of the body by stroking, rubbing, kneading, or tapping with the hands or an instrument. It is also the anointment, smear, or rubdown of the skin with oil or a specific cream. Massage art is based on the idea of touch that can heal. The Pharaohs practiced massage and touch therapy more than 4000 years ago, and so did Hippocrates, the Greek physician, in the fourth century BC. The church in the Middle Ages saw the manipulation of the body as the work of the devil and tried to prohibit massage. Massage improves body image in those with obesity and eating disorders. It improves stiffness and pain in those with arthritis by stimulating the circulation and soothing both the muscles and tendons. It is useful to treat tension, anxiety, insomnia, and both physical and mental exhaustion. Massage also helps to decrease the consumption of coffee, alcohol intake, and cigarette smoking. It also treats migraine, asthma, and paresis.

Touch is another healing power, especially for children. It is the first sense to develop in humans and may be the last to fade. Children from 6 months to 5 years having a daily 15-minute massage seem to be more alert, more responsive, and able to sleep more deeply according to Touch Research Institute in Miami, Fla. Touching has excellent effects on children's growth, development, and emotional well-being. The procedure is done by applying the light pressure of the fingertips in gentle downward strokes to the back and the chest or the palmar aspect of the fingers and/or the palms in touching and massaging the abdomen and extremities. This can be useful to treat stomach pain and get rid of gases. It is also useful for premature babies and helps in their recovery, both mental and physical. Touch has also social, educational, cultural, and humanitarian aspects.

Tattooing has been a well-known and practiced art for several centuries. Originally it was associated with religious ceremonies and fertility and marriage rites. It is still a common practice in Middle Eastern and Far Eastern countries, as well as in Europe and other Western countries. It is often a symbol of gang membership, and a common practice among army personnel. However, many do it for the sake of identification. Tattooing is still practiced by the Arabs as a tribal habit and decorative and beauty sign, which is done mainly on the face and hands. The techniques include the use of needles to introduce the particles of pigment into the dermis. The pigments are chosen according to the psychological factors of tattooed individuals. Blue-black is carbon, red is cinnabar, green is chromic oxide, yellow is cadmium sulfide, and brown is iron oxide. Tattoos can be in the form of lines, dots, figures, names of individuals, especially lovers, or as a sign of one's career (in the form of anchor or bower in sailors or mariners). Tattooing is also done in forms of animals, birds, dragons, or snakes since people believe tattoos protects them from evil and sickness. Tattooing is also done in certain shapes to frighten others and intimidate enemies.

Tattooing is done usually by a professional tattooer who marks or colors the skin with tattoos. The act of tattooing is an indelible mark or figure fixed on the body by insertion of one or more pigments under the skin or by production of scars using needles or scarification.

Tattooing was known for centuries as an alternative medical practice too. It was mainly performed by Buddhist monks, using a long needle to tattoo mainly the back and/or shoulders. The tattooer first puts his right hand on the tattoo place, and mutters or murmurs some kind of a prayer for a few minutes. The technique is painful but people believe that it brings them happiness and protects them from illnesses. At the same time they also believe that it has the power of a spell or incantation and talisman. They believe that tattooing acts as exorcism and protects the body from a sword, a chaser, or a bullet. This is why tattooing is applied on the face as a protection from enemy swords, or the back, chest, and abdomen for the same belief. Tattooing is also a ritual and is done in a liturgical or religious ceremony when incense, especially frankincense or cyclamen sticks are burned, and flowers are placed where the ceremony is held. Tattooing has many complications such as introducing simple pyogenic infection or tuberculosis, syphilis, infective hepatitis, or acquired immunodeficiency syndrome through unsterilized needles. Allergic reactions to the pigment and developing keloids or hypertrophic scars might also occur.

Modern tattooing for esthetic purposes features a special dye introduced to the upper part of the dermis using needles. It is practiced in the Middle Eastern countries and Europe for drawing lines or creating thicker eyebrows or eyelashes or lip lines.

Body piercing is basically the technique of piercing the earlobe with a needle or a special piercing instrument to apply an ornament such as earrings or eardrops of different shapes. The ornament can be made of gold, silver, chrome, or any other metal. Nowadays ear piercing has been modified to have more than 1 piercing and more than 1 earring, and it could be 4 or more. Body piercing is known as a tribal fashion in some Arabian and African countries and is used for the nose, lips, and tongue. Today, even in the New World, some young people who reject the norms of the established societies are practicing body piercing in unusual ways. Piercing, in addition to the ears, is also done to the nose, tongue, nipples, navel, and also the vulva. This practice coincides with the way such individuals reject society by dressing unconventionally or favoring communal living.

Body piercing has adverse effects such as secondary infection and the risk of contracting acquired immunodeficiency syndrome through unclean needles.

It is believed that one fifth of the world population has chronic insomnia, and difficulty sleeping without the intake of hypnotic drugs. Benzodiazepines and/or alcohol are used to help promote sleep, which can cause dependence, habit forming, or addiction after 4 to 6 weeks of continuous use.

The natural sleep process is a pattern created by the electromagnetic field produced in the brain by a combination of different radiofrequencies, which may stimulate the production of neurotransmitters or the electromagnetic field to promote the release of hormones, such as melatonin and serotonin that help promote sleep. The most common causes of insomnia are psychological in the form of worries, anxiety, fears, depression, and excitation. Sometimes the bed is too hot, too cold, too short, or has a bad mattress. Cigarette smoking late at night will create a nicotine effect that keeps one awake, or any change in sex habits.⁵³ The natural rhythm of sleep is disrupted in those who are frequent travelers and have jetlag, or others who develop nightmares.

Sleep loss exhibits potent effects, including decreasing cognitive abilities, alertness, and work performance. Fatigue experienced during the day following loss of sleep is risky from physical, emotional, and social standpoints. Hypnotics used to help sleep lead to daytime drowsiness, headache, poor concentration, and reduced memory in relation to place and time.

Lack of sleep affects the ability to drive or operate a machine and is followed by a hangover. Sleep can be disturbed, reduced, or completely prevented by anxiety, tension, mental exhaustion, change in bedtime habits, presence of strong light or noises, or following a heavy dinner, or in the presence of illness or due to intake of medications.

Alternative therapies for insomnia that help trigger sleep include relaxation or cogitative mental exercise. A simple exercise is, for instance, taking 3 deep breaths very slowly, exhaling fully each time, then stop breathing for as long as you can and repeat this 5 to 6 times. This breathing exercise causes a tranquilizing effect because of the accumulation of carbon dioxide in the blood. A warm bath may help, and a sound-masking device or a mask to cover the eyes are also useful methods to sleep. Drinking hot milk or hot chocolate, reading a story, listening to soft music, and to avoid thinking of daily matters could help induce sleep too. Some herbal medications are noted to help induce sleep, such as the African passion flower and passion fruit, the South American passiflora, the English Humulus lupulus hops and motherwort, chamomile, lemon balm, linden flowers and leaves, and wild lettuce. Children can sleep easily if stories or tales are read to them, they hear songs, or have a gentle-touch massage.

Physical activities, exercises, and training are for pleasure and relaxation. They are outlets and help to alleviate stress, frustration, and tension. Different games and sports are also forms of self-expression, give confidence to a person, makes one feel satisfied and/or important, and encourage winners in sports to achieve more goals in life. Heavy exercises help induce sleep, some build strength of the body and soul, and some improve alertness. Spiritual, religious exercises, and devotions are also useful to treat many emotional, psychological, and physical problems, especially if they are combined with music.

Accepted for publication May 28, 1998.

I thank Hala Fattah, PhD, researcher of history, at the office of HRH Crown Prince El-Hassan bin Talal of Jordan for her assistance in editing the manuscript. I also acknowledge Inam Khayat, my secretary, for typing the manuscript.

Reprints: Oumeish Youssef Oumeish, MD, FAAD, FACP, FRCP(Glasg), Amman Clinic, PO Box 65, Prince Rashid Suburb, Amman 11831, Jordan.