Concept of Abdaal e-Advia (Therapeutic Interchange) in the Light of “Maqala Fi- Abdal Al- Adwiya Al- Maustamala Fi -Al -Tib Wa Al- Ilaj” Known as “Kitab Al- Abdal”

The problem of non-availability, confused identity, and drug adulteration exists in Unani medicine system. This is because it has to deal with hundreds of herbs and drugs of mineral as well as animal origin.¹ Certain drugs are native to certain countries even if they grow in other countries; the best species is still found in a particular region of the world. Under these circumstances, certain drugs of prime therapeutic value and choice may not be available to the physician, thus hampering the process of successful treatment. Consequently, the need to search for therapeutic interchanges has arisen. Ancient Unani scholars have also given the concept of the therapeutic interchange of drugs since antiquity, and even classical Unani literature has amply talked about therapeutic interchange of almost all single drugs. Though in many books written on Ilmul Advia (Unani Pharmacology), the concept has been specified, many of them have given therapeutic interchange of single drugs only, leaving the rules aside.^2–4 However, some have mentioned the principles and regulations also, but they are scarce.^5–7 One such skilled medical professional who understood the significance of this subject was Razi, also referred to as Rhazes in the West. Razi is the first Unani scholar who has given this idea significant consideration, applied his thinking, established some guidelines, and developed a technique to implement therapeutic interchanges. “Maqala Fi Abdal al-Adwiya al-Mustamala Fi al-Tibb wa al-llaj” was one of his most remarkable contributions, usually referred to as “Kitab al-Abdal”. This is earliest surviving text on the specific therapeutic substitution of single drugs in Unani medicine.^1.

Kitab al Abdal- the book that details the therapeutic interchange of drugs, was explored in detail regarding the information it contains. It was explored for the systematic study of the principles underlying therapeutic interchange, and various observations were noted that were specific to the book. Additionally, all the parameters considered for “Kitab al-Abdal” have been classified, along with 223 therapeutic interchanges of the 122 primary drugs.

Razi, a biographic note: “Abu Bakr Mohammad Bin Zakariyya-Razi” (Rhazes), a great physician, was born in the city of Ray (Iran) in 240 Hijri (864-925 AD). According to Ibn-e-Abi Usaiba, he had great interest in Philosophy and literature right from a young age and used to compose verses, and was very much fond of music. He was a keen observer, experimenter, and excellent author. He took particular interest in Philosophy, Astrology, Metaphysics, Physics, and Mythology and wrote many books on these disciplines (Table 1).^1,8

According to Uyoon Al Anba, he visited dawakhana Azdi, Baghdad, and learned how the first drug, “Hay ul Alam” evolved, which made him curious about medicine, and he started studying medicine after 30 years of his age.⁸ His academic status is credited to the study of Greek scholars and his attachment to the contemporaries like Abu Zaid Balkhi and Ali Ibn Rabban Tabri.^9,10 He also studied Galen thoroughly. He was a man of outstanding personality in context of his comprehensive study, keen observations, therapeutics, and writings. On one hand, he made use of Greek and Syrian knowledge, whereas, on the other, he studied Indian medicine and was greatly impressed by Sushrut.^9–11 Medicine in his time was in poor shape, and only sixteen books of Galen were available, with some interpretations of Galen by Alexandrian writers and few books by contemporaries.¹ He examined, selected, and compiled scattered information systematically. The following phrase, which eventually became a proverb, depicts the picture well. “Medicine was dead Galen gave life to it. It was scattered Rhazes streamlined; it was incomplete-Avicenna completed it.¹

He spent some years of his life as CMO in a great hospital in Baghdad. He was the one to differentiate between smallpox and measles. He also gave the idea of selecting the most appropriate location for the hospital by hanging pieces of meat on likely sites and then selecting the one with the least purification.^9–12. Later he resigned and started his own practice in his native place. He had developed Conjunctivitis in adolescence, which caused him total blindness until he died in 320 Hijri.^9,12 Various interesting case studies exist in different books, like Uyoon al Atiba and History of Medicine (Louis Magner).⁹

Exact number of books written by Razi has yet to be discovered. Each scholar has different opinions about the no of books he authored. Razi is termed “indefatigable” by Louis Magner because he wrote 200 books.⁹ According to Uyoon Al Anba, there is a list of 220 books with names that were authored by him.⁸ List of books mentioned in Kitab al Abdaal Abdaal (Table 2) by various authors are) Ibn e Nadeem- 167, Jamaluddin Qifti -137, Ibn e Abi Usaiba -244, Abu Rehan-184, Molana Abdus Salam Nadwi -29.¹

“Kitab al-Abdal,” also known as “Maqala Fi Abdal Al-Adwiya Al-Mustamala Fi Al-Tibb wa al-Ilaj,” is a significant contribution of Razi which is essential from a pharmacotherapeutic point of view. This book is in Arabic language and is just 15 pages. “Central Council for Research in Unani Medicine”, under its literary research program first time in 1980, published the edited Arabic text of this book along with translation and explanatory notes.¹ It was felt that such a rare book should be translated into English so that majority of scholars across the globe may be benefitted. Several Manuscripts of this book exist in India. Four manuscripts were under study while editing and translating this book retrieved from the Rampur Raza Library, Asiatic society Kolkata, Khuda Baksh Oriental Library, Patna, and a private collection at Aligarh.¹³ It has also been translated into Persian and is available in the library of Aastan e Qudus Rizvi. This manuscript is preserved in Aya Sophia, Majlis Shura e Milli, Iran, and Library of Aqa Muhammad Ali Tarbiat.¹

It is a fact that ancient physicians did not think the subject of therapeutic drug interchanges worthwhile for scientific learning, which is evident from classical books because none of them have chapters on such a vital aspect of therapeutic interchanges.¹⁴ Also, no writer discussed the related problems because scarcity of drugs was rare. Razi was foresighted and described the importance of the subject as follows: “the way I have studied this vital part of medicine, it deserves a separate book on this topic which would help physicians because all drugs are not available at all places.

So, if the physician is unaware of therapeutic interchanges which are used in place of primary drug, the objectivity, and benefaction of medical profession would cease.¹ The credit goes to Zakariya Razi for compiling all the information and bringing it to one book and also for framing the principles. He was more qualified to write this book because he was the person who remained attached to hospital for a certain period and served as a general practitioner for the rest of his life. The fundamental principles, uses, dosages, and other details of the various therapeutic interchanges for 122 single drugs are covered in this book in a systematic and succinct manner. Some of the drugs covered in this book were indigenous to the author’s home country of Iran.

Rhazes, while working on this book, consulted the Greek and Arabic writings of his predecessors like Jame-Irmas, Jame Bolus, and Galen’s translation by Hunain bin Ishaque. Razi quotes, “By this time, I had finished writing this book. I did not come across any such book in which a technical and scientific approach was resorted to except Hunain bin Ishaque’s work. I also observed that in therapeutic interchange of drugs methodology, Hunains understanding and logic is far better than his predecessors”. The author has also referred to the books like Jam’e Ibn-i-Masawaih, Mayamir li Jalinoos, Adwiya Mufrada li Jalinoos, Tadbir al-Asiha, Jame’ Irmas, Jame’ Hunain and Jame’ Bolus. The author has quoted physicians Ibn Masawaih, Bolus, Bodighorus, Galen, Qunitus, Dioscorides, Masarjoya Hunain bin Ishaque and Irmas in the book.¹

This original book has also been cited in other works as a significant treatise. The importance of this book could be guessed from the fact that famous botanist Ziauddin Ibn-e-Baitar in his book “Jame’ li Mufradat,” has described 27 drugs therapeutic interchanges (Table 3) with reference to Kitab al-Abdal:^1,2

There are excerpts of Kitab-al-Abdal in Minhaj-ud-Dukan. Ibn-e- Nasar A Attar Israili, in his famous book Minhaj-ud-Dukan, acknowledges the contribution of Rhazes, saying, “The drugs whose therapeutic interchanges are mentioned in Minhaj-ud- Dukan have been taken from Kitab al-Abdaal and some other books.¹⁵ The edited book contains annotations wherein Arabic name, Persian name, Urdu and Hindi name, English name, Botanical name, and pharmacological description (Mizaj, Actions) of main and therapeutic interchange drugs (A,b,c) are mentioned (Table 4).

Therapeutic interchanges of 122 drugs have been mentioned, and many main drugs have more than one therapeutic interchange. Fifty-six drugs have one therapeutic interchange; thirty-nine drugs have two therapeutic interchanges; nineteen drugs have three therapeutic interchanges; eight drugs have four therapeutic interchanges. Razi was cautious while allocating therapeutic interchanges; he had considered various aspects while discussing therapeutic interchanges. Some essential parameters which were contemplated by Rhazes are:

Weight: Therapeutic interchanges weight is mentioned in relation to main drug (Table 5). Out of 122 drugs, therapeutic interchanges of 78 drugs have been mentioned in what desired weight they can be taken as therapeutic interchanges. e.g., Shahm e Hanzal is therapeutic interchange of Habb al Neel in half weight.

Action: Razi has discussed therapeutic interchanges for many actions. A drug is a therapeutic interchange for another in which action is mentioned only in 40 drugs, (Table 6) while for other main drugs, actions are not specified. eg, Shahtra is therapeutic interchange for Badward in chronic fevers, and Abresham is therapeutic interchange for Badranjboya as an exhilarant and cardiac tonic.

Arabic name Used: Author has mentioned drugs in Arabic names. eg Sheeh Armani, Labn ul Luqah, Hazar Jashan, Kamazariyoos etc.

Therapeutic interchanges of different origins: Therapeutic Interchanges of different origin drugs are mentioned. Plant-origin drugs being a therapeutic interchange of animal/mineral origin drug and vice versa (Table 7).

Mizaj (Temperament): In majority of the drugs, the mizaj is the same as the main and therapeutic interchange, but in two cases, there is majority slight variation in mizaj. (Table 8) E.g., Roghan e Kewra, which is cold and moist, is therapeutic interchange of Roghan Al Balsan, which is hot and dry.

Badrqa: The author has also mentioned the badrqa (adjuvants) to be taken with therapeutic interchanges Irsa-Mazariyoon 1/3 of its weight with three ounces of Camels milk for inducing watery purgation. Similarly, Tukhm e Badiyan, half its weight with 1/3 of sweet almonds, is therapeutic interchange of Afzar.

Compound drug therapeutic interchange: Therapeutic interchanges of compound drugs (Table 9) have also been mentioned, like Dawa al Qust-Dawa al Kumkum and Dawa al luk. Also, therapeutic interchange of single drugs is compound drugs like Dohn e Yasmeen is the therapeutic interchange of Labani (Mea e Saila). Also some oils therapeutic interchanges have also been described. e.g., therapeutic interchange Roghan-e- Hina is Roghan-e-Marzanjosh and therapeutic interchange for Roghan-e-Gul is Roghan-e-Banafsha.

Citations in the book: Reference has been mentioned clearly in the book’s text against the therapeutic interchanges taken from other sources. According to ibn Masawih, therapeutic interchanges of nine drugs are taken; according to Galen, therapeutic interchanges of seven drugs are taken. According to Badighorus, Bolus, and Discoridues, one is taken.

Antidote: Antidotes are mentioned as Therapeutic interchanges. Jadwar as antidote, Zaranbad weighing three times, Zait –Zubd (butter) as antidote to toxic drugs.

Potency: The potency of some therapeutic interchanges has been mentioned:

Galen says in “Tadbir Al-Asiha” “use Salikha of good quality in place of Darsini in Ayarij Fiqra, which is closer to Darsini in potency. Nevertheless, good Darsini is always better than good salikha, but I do it out of necessity when Darsini is unavailable”.

Dohn Al-Khirwa (castor oil): Galen says that potency of Dohn al-fuji is equal to that of Dohn-ul-khirwa, but Roghan Bed Anjeer (Castor oil) is much similar to old olive oil. Hence it should be preferred as a therapeutic interchange to castor oil.

Dohn Al-Qurtum: This oil is same as Anjarah oil except that Roghan-e-Anjarah is weaker.

Zarnab: Used with kababa, its potency is equal to that of salikha, and it is a good therapeutic interchange for darchini Maserjoya says its potency is equal to Jauz tib, lighter than zarnab.

Hamama: Its potency is the same as Waj. Hamama is more cathartic, and Waj is more dessicant, so it would be better that while using Hamama a retentive is added and a laxative while using Waj.

Farbiyoon-Hilteet is being used because fresh Farbiyoon produces more heat than hilteet

Laghiya: Galen says that its potency is equal to that of Farasiyoon, so it should be used as a therapeutic interchange, while others say that Laghiya is less active than Farasiyoon.

Sakbinaj: Galen, in his article “Al-Adwiyatil Muqabila Lil Adwa,” says that Qinna can be a therapeutic interchange, primarily white Qinna. However, its potency is less than Sakbinaj, i.e., with respect to being an antitode to lethal poisons.

Species: Species of one genre of a plant are the therapeutic interchange of each other, e.g., for Artemesia absinthinum, Artemesia maritima Linn., and Mentha piperita Linn, Mentha aquatica Linn is used.

Rare drug: Some rare drugs are used as therapeutic interchanges, e.g., the skin of Samoor, Ezam Aswaqt al Ghazlan. Yatuat means all plants that secrete toxic latex are called Yatuat. The following seven plants are recognized in this category- Ushq (Madaar), Laghiya, Artanisa, Mahu, Dana, Mazriyoon Bantafiloon, Shibram and Sadawaran (A type of gum found on Bun trees is also discussed), its therapeutic interchange is Feel zahraj (Rasaut).

This is first book on this subject. Razi benefitted from the views of all his predecessors and added his own observations and clinical experiences. The edited book is the only book that has compiled fundamental principles of therapeutic interchange of drugs. This book provides valuable information in a clear and organized manner about the uses, dosages, and other therapeutic interchanges for 122 medications. To therapeutically interchange a drug, some rules have been devised so that when a drug is interchanged, it is tested on these parameters and new alternatives suggested.

In his book “Canon,” Avicenna advises that therapeutic substitution should only be employed when the intended medicine is unavailable.⁶ Avicenna is very cautious in suggesting therapeutic interchanges for single drugs. That is why he has described just sixty one therapeutic interchanges from a long list of seven hundred eighty one drugs mentioned in al-Qanoon. Therapeutic interchanges for other drugs have yet to be specified.⁶

Rhazes has also quoted the following principles for the therapeutic interchange of drugs from Galen’s book, “Al Adviyat-al-Maqabela Lil Adwa”. “If you need a single drug of good quality which is unavailable, use a drug of reduced quality, it will be less harmful. Then if you want to prepare a compound drug of which one single drug is not available, reduced quality drug double the weight of the original drug can be used. Thus, the efficacy of the drug would remain same” No drug can completely replace another drug therapeutically in all aspects, according to Avicenna and Rhazes. To quote part of al-Qanoon, “Badalahu fima zaama bazuhum al khas fi jamee’ af ‘alihi”. Avicennas does not give any weightage to the view of some physicians that Khas could be a therapeutic interchange for Dam al-Akhwain in all its actions.^1,16

It is similarly vital to be explicit for which action a particular medicine is replaced by another because it frequently happens that a drug is therapeutically substituted for another drug for a specific activity, even though the latter’s other effects may be quite different. Secondly, if a medicine is therapeutically interchanged with another drug that has the same property, the second drug should be the original drug’s therapeutic interchange for that activity, even though the second drug can be replaced by a third drug for a different action.^1,16,17

It is essential that the temperament of original drug and therapeutic interchanged drug should match. For instance, the therapeutic interchange should be hot and dry in the first degree if the medicine is hot and dry in the first degree; but if therapeutic interchange is hotter and drier, the dose of it should be less than the original drug. Similarly, if the therapeutic interchange is of lower temperament, the dose should be increased. It is not possible that a drug of hot and dry temperament could be therapeutically interchanged by a cold and moist temperament drug.^1,16

There are numerous instances where a drug of one origin is substituted with a drug of another origin. For instance, a medicine of animal origin may be therapeutically replaced with a drug of plant origin, e.g., therapeutic interchange for Jund Bedastar (Castor fiber L) is Mirch Siyah (Piper Nigrum L.) half its weight.

Avicenna has described the therapeutic interchange in the same way, “Therapeutic interchange for Jund (Castor fiber L) is equal weight of Waj(Acorus calamus L.) with half weight of black pepper (Piper nigrum L.).” According to Avicenna, an animal-origin medicine may be used therapeutically in place of a drug with a plant origin. For example, Zaufa ratab is a therapeutic interchange for Mukh Saqul Baqar (Bone marrow of cow legs). One species of a plant could be a therapeutic interchange for the plant of other species. Rhazes, quoting Galen, says that therapeutic interchange for Podina Kohi (Mentha) is Podina Nahri (Panny Royal).^1,16,

Sometimes another part of the same plant serves as therapeutic interchange. For instance, as in the case of blood purification, another part of the same plant is used if a particular part of the plant or tree is unavailable. For example, if Margosa flowers are unavailable, Margosa leaves, or bark is used. According to this principle, therapeutic interchange for Persiawashanan (Maiden hair fern) is Sosan leaves (Lily) with Banafsha (Violet) or Sosan root.^1,16

In most drugs, the author has appropriately mentioned the desired weight, which they could prove as therapeutic interchanges. The basis of the therapeutic interchange of drugs is based upon action and temperament. However, a fair comparison between the therapeutic interchange and original drug must be made regarding whether or not both drugs have the same temperament and how much they correspond with each other in actions. Besides, in what diseases they could be therapeutically interchanged. When a therapeutic interchange is suggested as an alternative, the possibility of a particular medicine serving as a therapeutic interchange for a given disease and drug should be discussed and stated. In this context, different kinds of research can be conducted. One is literary research, which allows for pharmacological and phytochemical comparisons after a literature review.¹⁷ The second approach may be clinical, which would involve testing the medications on actual patients and recording which medication would take the place of another and how they are comparable. Thus, such distinctive fundamental elements for the therapeutic interchange of medications can be considered for future topic of scientific investigation and harmonization. However, this book is a milestone in respect of medicinal therapeutic interchanges and opens new avenues of research for exponents of medicine.