REGIMENAL THERAPY IN UNANI MEDICINE WITH FOCUS ON PURGATIVES – AVICENNA’S APPROACH

REGIMENTAL THERAPY IN UNANI MEDICINE WITH FOCUS ON PURGATIVES – AVICENNA’S APPROACH

Zaheer Ahmed ^{* 1}, Anzar Alam ¹, Ghufran ¹, K. Rabee ², M. A. Qamri ¹ and Najeebul Hasan ³

Department of Moalajat (Medicine) ¹, Department of Kulliyat (Basic principles) ², C.R.U, C.C.R.U.M ³, N.I.U.M, Bangalore-560091, Karnataka, India.

ABSTRACT: Proper and normal functioning of the bodily process must be ensured in order to maintain perfect health. Any disturbance in the normal humoral balances whether it is excess, diminution or blockage leads to disease stated Avicenna (980-1037 A.D) the revered Greco Arabic physician and author of world-renowned treatise “Al Qanoon fit tib.” He has treated certain diseases by regulating metabolic processes through various modes of treatment. Regimental therapy is one such core method of treatment through which the morbid matter is eliminated or its excessive production is checked, or its spread is arrested and resolved by certain special techniques and thereby restoring humoral equilibrium. There are various forms of such therapy with details of its application. Purging is one such specialized method of regimental therapy through which deranged humor is eliminated from the body after proper administration of concoctive (Munzij). This therapeutic methodology is employed especially to combat certain ailments of sub-acute and chronic duration. The present communication is an attempt to highlight Regimental therapy with special reference to various aspects of purgation as surveyed from various Unani classical literature.

Regimental therapy, Unani medicine, Purgatives, Mushil therapy

INTRODUCTION: Proper and normal functioning of the bodily process must be ensured to maintain perfect health. Any disturbance in the normal humoral balances whether it is excess, diminution or blockage leads to disease. Ancient Unani physicians have from time immemorial treated certain diseases by regulating the metabolic process through various modes of treatment ^1-4.

“Al Qanoon Fit-Tib” has stated that treatment is carried out by following principles.

• At-tadbeer (Regimental therapy) and Taghzia. (Dietotherapy)
• Istemaal-ul-Adviya (Pharmacotherapy)
• Istemaal-e-Aamal-al-Yad. (Surgery)

According to him the line of treatment in the Unani system of medicine for Su’e-mizaj (altered temperament) is of two types:

Single altered temperament (Su’e-mizaj sada) which is best treated by Ilaj-bil-Zid (counter action)

Complex altered temperament (Su’e-mizaj Maaddi) where there is associated Khilt-e-ghair Tabayee (deranged humor)/Maad-e-Marz (morbid matter) that would require Istafraagh (elimination) which itself is sufficient but sometimes elimination has to be supplemented by some other remedial measures ^1-6.

Regimental therapy is one such core method of treatment through which the morbid matter is eliminated or its excessive production is checked, or its spread is arrested and resolved by certain special techniques and thereby restoring humoral equilibrium ^7-8. There are various forms of regimental therapy which is dealt with by Al-Qanoon which details about its principles, objectives, indications, and contraindications, method of application with its adverse effects, etc. some of them are: Mushil (Purging), Qai (Emesis), Fasd (Venesection), Hijamah (Cupping), Hamam (Turkish bath), Dalak (Massage), Riyazat (Exercises), Taaleeq (Leeching) etc. ^{1-4, 9}

Purging is one such specialized method of regimental therapy through which deranged humor is eliminated from the body after proper administration of Munzij (concoctives). This therapeutic methodology is employed especially to combat certain ailments of subacute and chronic duration. Mushilaat (purgatives) and Mulayyinat (laxatives) have been widely used by Avicenna for intestinal evacuation in certain diseases. This method has Muhallil (resolving), Raade, Daf-e-Tashannuj (antispasmodic) and Tanqia (detoxicating) effects ^{1-2, 4, 9-11}.

Avicenna has laid down certain rules for adopting this method in this famous treatise “Al Qanoon Fit-tib,” compliance of which is necessary because this method has a direct effect on the normal metabolic process.

General Principles of Istifragh (Elimination): For carrying out purgation, the following five principles should be kept in view:

• Only morbid matter required to be eliminated should be removed.
• Elimination should be in the direction of outflow thus griping should be treated with purgatives and nausea with emesis.
• Elimination should be through an appropriate organ and towards the one where morbid matter is drifting, e. Stomach and intestines.
• The time for elimination should be decided according to the presence or absence of Nuzj (maturation).

The quantity of vitiated matter to be eliminated should be estimated from

• The amount of matter in the body.
• The strength of the patient and
• The chances of complications ^1-4.

Objectives of Purgation:

• Diseases of humoral imbalance caused due to vitiated matter are best treated with purgatives.
• To reduce the heat of temperature in fevers.
• Purgatives benefit severe constipation and colitis.
• To eliminate excess fluids from the body. g., Ascitic fluid.
• To eliminate the excess of bile, phlegm, and black bile.
• To bring down the pressure in Hypertension.
• Sometimes carried out as prophylaxis. e.g., to prevent attacks of gout, bronchial asthma, and epilepsy expected with the advent of spring, etc. ^1-4

Indications and Contraindications: The factors to be considered in the use/disuse of purgation are:-

Plethora:

• If the body is in a full state of maturation purgatives are indicated.
• If in a state of depletion purgative is contraindicated.

Strength:

• All the three primary faculties should be in a sound state.
• The weakness of any of the three primary faculties contradicts purgation.

Temperament:

• Indicated in sanguine and phlegmatic persons.
• It is contraindicated in bilious and melancholic persons.

Physique:

• Purgatives are indicated in moderately built patients.
• It is contraindicated in lean and obese patients.

Age:

• Young and middle-aged persons are fit for purgation.
• Children and Old persons are unfit. Pregnant and menstruating women are also not suitable for purgatives.

Season:

• Season-wise purgatives are the best to use in spring and autumn.
• Contraindicated in the extreme hot and cold season (summer and winter).

Local climate:

• Purgatives are best suited for moderately hot southern countries and moderately cold northern countries.
• But are contraindicated in extreme hot and cold countries.

Habits:

• Only persons who are habitual are considered for purgatives.
• It should be avoided in unaccustomed persons.

Occupation:

• Purgatives are indicated in persons whose job doesn't demand extreme exhaustion (Mentally active jobs).
• Purgatives are contraindicated in all strenuous occupations. (Physically active hard workers).

Presence of any Specific Disease:

• Purgatives are best suited for persons whose digestive system is free from diseases.
• It is contraindicated in persons suffering from diarrhea, intestinal ulcers etc.^{1-4, 9-11}

General Rules of Purgatives: The following rules should be observed before starting purgatives:

• The food taken before purgation should be small in quantity.
• If the bowels are already loose, there is no need for any preparation.
• Strong purgatives should be avoided by those unaccustomed; however mild purgative such as confection of Banafsha (Viola moderate) with sugar is a beneficial type.
• Good sleep is recommended before starting purgation.
• Anus should be washed with warm water before purgation.
• Those desirous of taking a purgative should take less salt with meals.
• Purgatives act best when they are taken during spring or autumn and unsuitable in extreme summer and winter seasons.
• Those with the bilious stomach as also those dieting or fasting should eat bread soaked in wine before taking the purgative which helps rather than hinder purgation.
• Baths are one of the best means of purgation if taken regularly for some days before purgation helps to liquefy the vitiated matter.
• However, some interval between the bath and purgation has to be there.
• The bath should not be taken immediately after purgation as the morbid matter would then get diverted towards the skin and thus hinder rather than help purgation.
• When strong purgative such as Kutki (Picrorhiza kurroa) is to be given to a person with a dry temperament or a strong stomach, some fatty foods should be served beforehand to moisten the system.
• Persons of hot temperament with delicate system and stomach should take Isaphgul (Plantago ovata) with cold water, oil of Banafsha (Viola moderate) with sugar or honey, or barley water, pomegranate juice or some other light food before purgation.
• Before giving a purgative, the body should be prepared by loosening the matter with munzij (concoctives) and opening the channels with a mulayyan (laxative). This is particularly important in the treatment of cold diseases/where the humor is viscid.
• A preliminary laxative should, however, be avoided in a person with a tendency towards diarrhea. A mild emetic should be added in the prescription so that the purgative does not pass down quickly.
• Purgative can be dangerous if the bowels are loaded with dry scalable. It should first be removed with an enema or some emollient preparation which lubricates the bowel.
• Massage and oil rubs assists purgation ^{1-4, 11-12}.

Rules to be Observed During and After Purgation:

• Undue movement and activity are not advisable after purgation. There should be a short period of rest, after which gentle walk is recommended which assist purgation.
• Nausea caused by foul odors of purgation should be checked by smelling Pudina (Mentha arvensis), Barg-e-sudab (Rutea graveolens), Karafs (Apium graveolens) sprinkled with vinegar or rose water.
• If the drug is unpalatable, the pill is smeared with honey or is coated with sugar or honey.
• If vomiting is imminent, some suitable astringent is given soon after purgation some suitable astringent given soon after the purgation.
• It is also important that the feet and abdomen should be kept warm and well covered.
• Food and sleep should be avoided immediately after purgation.
• Purgatives are difficult in cases of inflammation of abdominal viscera. In such cases, mild purgative drugs such as Lablab (Lablab purpureus), Tukhm-e-quantum (Carthamus tinctorius), Bisfaij (Polypodium vulgare), Amaltas (Casia fistula) should be used.
• After purgation, no any irritant like vinegar, alcohol syrup should be given for two or three days.
• The strength of the patient should be maintained to cope with the ill effects. Heart tonics are especially advisable to strengthen the vitality of all organs, make the humor light and thin and also assist purgation.
• When a purgative leaves its odor and gives the feeling that some more is left out, granulated flour of roasted barley should be taken.
• Sips of warm water and barley water are very helpful in avoiding the after effects of purgation and also help in flushing the excretions adherent to the intestinal wall.
• Persons with cold temperament and excess of phlegm should take Habb al-rashaad (Lepidium sativum) washed with hot water and dress with Olive oil after taking purgatives.
• Those of balanced temperaments should take Buzr-ul-katan (Linum usitatissimum) ^1-4.

Mode of Action of Purgative Drugs:

• A prescription with the ingredients not varying widely in their action and time is the best purgative.
• Purgative besides producing diarrhea act through their specific properties. Some are resolvents (muhallil), g., Turbud (Ipomoea turpethum), some stimulate peristalsis in the bowels, e.g., Halela (Terminalia chebula), some drugs besides being laxatives, soften the stools e.g., Turanjabeen (Tamarix indica gum), some purgatives clear the bowels by making the matter slippery e.g., Isapghul (P. ovata) and Ajas (Prunus domestica).
• Powerful purgatives are generally somewhat poisonous and act by overpowering the system. Hence, they should always be combined with Tiryaqat (Antidotal correctives).
• Such qualities as bitterness, sharpness, pungency, and sourness, , generally enhance purgation. Thus bitterness and sharpness assist by resolving, pungency helps expulsion and sourness makes the passage smooth by its cleaning property.
• Purgatives with slow and delayed action should always be combined with a proper adjuvant to enhance their activity, g., Zanjabil (Zingiber officinalis) with Turbid (Ipomoea turpethum) accelerates the action of the latter.
• When the drug used for eliminating the offending humor is of similar quality, g., (Convolvulus scammonia) for clearing bile, it is better to combine with a drug of opposite quality, but the one which aids are at least doesn't hinder purgation. e.g., Halela (T. chebula). A purgative may act as an emetic when a) the stomach is weak, b) the patient is passing dry scybalous stools,) the medicine is unpalatable and nauseating, d) when the patient is suffering from dyspepsia.
• The humor drawn by purgatives is specific to each purgative. Thus a purgative might draw thick but not thin humor.
• Purgatives always draw the matter from the channels (used for absorption).
• Purgatives not only withdraw the matter from the organs situated above but also loosen it from those below. So, purgative eliminate matters in both natural and contrary directions.
• The decoction's action should be similar to that of pills given along with, e., always purgative pills should be supplemented with suitable decoctions. The proper decoction to eliminate bile is the decoction of Shahatra (Fumaria indica), while for black bile, decoction of Aftimoon (Cuscuta reflex), Bisfaij (Polypodium vulgare), etc. and for phelgm is decoction of herbs such as Qantoorin (Centaurea centaurium) ^{1-4, 11-14}.

Signs of Successful Elimination:

• There is no restlessness or disturbance after elimination.
• The discharge of a new type of matter, after the clearance of offending material, is a sign of successful elimination.
• The overwhelming desire for sleep.
• Next day when the bath feels pleasant and soothing, it denotes elimination of the residual matter.

Signs of Excessive Purgation:

• Excessive thirst is an indication for arresting purgation.
• Nature of stools indicates the need for stopping purgation.
• Expulsion of blood after purgation is a sign of danger.
• Dry tongue, cold skin, and loss of skin turgosity are other signs of excessive purgation.
• Passage of shreds from the lining membranes of bowels and dark, foul smelling matter in the feces are indicative of stoppage of purgative therapy ^{1-4, 11-12}.

Treatment of Excessive Purgation: It generally results from:

• The weakness of the vessels
• Widening of the passages
• Irritation of vascular orifices
• The temperamental or other allied abnormalities
• Excessive purgation stopped by tightly bandaging the arms and legs beginning above at the armpits and groin.
• The body should be massaged and astringents gave orally. It is also advisable to massage the limbs to keep the body warm or keep the hands and feet soaked in warm water.
• Purgation can also be arrested with emesis induced by warm water.
• Purgation and venesection both produce pain in the region of liver. This is cured by hot water drinks.
• A suitable antidote such as theriaca or a small quantity of philonium (a compound according to Galen was originally introduced by Toosi for treating various types of pain especially colics - it contains Afyoon (Papaver somniferum), Ajwain ( ammi), Farfiyoon (Euphorbia antiquorum), Aqarqara (Anacyclus pyrethum), etc.) should be given and sweating induced with a hot water bath or hot vapor bath.
• The essence of sandalwood, camphor or some fragrant fruit should be presented for smelling which also induce
• Oils of Behi (Pyrus cydonia), Mastagi (Pisticia lentiscus) and plaster made from crushed roasted barley should be applied over the abdomen.
• The piece of bread soaked in pomegranate juice to be given.
• Dishes made of crushed roasted barley or Tukhm khaskhash (Papaver somniferum) are also helpful.
• An excellent and well-tried prescription is three drams of bruised watercress boiled in buttermilk until the whole burnt solid. The diet should contain an astringent such as the juice of sour grapes cooled with ice.
• Excessive purgation from poisonous herbs such as Mazerioon (Maseru) and shibran (Spurge laurel) is treated with curds.
• After purgation when there is a risk of ulceration of bowels Bore- Armani ( bore) and pomegranate juice are given.
• When a purgative produces fever by agitating and exciting the blood, barley water is the best remedy or venesection would be sufficient for its treatment. If these measures fail to stop purgation, a more drastic treatment as given in diarrhea would be necessary ^{1-4, 11, 13-14}.

Management of Ineffective Purgation:

• When a purgative fails to act, it produces griping, restlessness, headache and yawning; this is best treated with a suppository or warm water enema with forty grains of pow-dered Mastagi ( lentiscus) dissolved in it.
• Astringents such as Behi (Pyrus cydonia) and Seb (Malus domestica) increase the peristalsis of stomach and intestines, check nausea and propel the purgatives onwards. Moreover, they help to strengthen the body.
• If the failure of enema results in the tension of the body and bulging of eyes, it is a sign of enema having pushed the morbid matter upwards, this makes venesection necessary.
• When a purgative fails to act with no after effects, venesection should be carried out even after two or three days, lest there is a danger of morbid matter drifting towards the vital organs ^{1-4, 12-14}.

CONCLUSION: To conclude, the glimpses taken from Avicenna's magnum opus, AI-Qanoon-fil-tib and other classics reiterates the fact that purgatives play an important role in the treatment of chronic diseases in Unani System of Medicine provided the therapy is judiciously administered, i.e., preliminary concoctions, then purgatives followed by drug therapy; with all the given specifics taken in to consideration. Besides the fundamental importance of this therapeutic methodology, there is a problem of a lack of uniform standards for the present generation. It therefore apparently seems essential to standardize it and to develop certain scientific parameters for evaluation of the efficacy of this therapy so that the benefits may reach to the larger sections of society. This therapy must also be evaluated for prophylactic use so that some of the impending attacks/bouts of disease, i.e., in gout, bronchial asthma, epilepsy, etc., can be averted.

ACKNOWLEDGEMENT: The authors gratefully acknowledge the assistance rendered by the staff of the central library of N.I.U.M, Bangalore in providing the pertinent material for the preparation of this manuscript

CONFLICT OF INTEREST: Nil

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    How to cite this article:

    Ahmed Z, Alam A, Ghufran, Rabee K, Qamri MA and Hasan N: Regimenal therapy in Unani medicine with focus on purgatives – Avicenna’s approach. Int J Pharmacognosy 2014; 1(7): 409-14. doi: 10.13040/IJPSR.0975-8232.1(7).409-14.

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