Hasaat-e- Kuliyah (Nephrolithiasis)
Hasaat-e- Kuliyah (Nephrolithiasis/ Kidney stone/ Renal Calculus) is one of the most common health problems, which affect approximately 15 % population worldwide. While in India approximately 2.3% population is affected by this disease.
Composition: It is crystalline, hard mineral material formed within the kidney or urinary tract. In other words it is a concretion, crystalline mass or a solid accumulations of material. It is formed by precipitation of various urinary solutes in the tubal system of the kidney.
Size: It’s size varies from as small as grains of sand to large as golf ball.
Urolithiasis (Hisaat-e- Bauliyah) is a term originated from three Greek words, “ouron‟ for urine, “oros‟ for flow, and “lithos‟ for stone. It is the process of formation of stone in the urinary system, which includes Nephrolithiasis (Hisaat-e- Kuliyah), Ureterolithiasis (Hisaat-e- Haalib) and Cystolithiasis (Hisaat-e- Masaanah).
Hasaat-e- Kuliyah (Kidney stones also called renal calculi) cause problems when they block urine flow inside or outside of the kidneys. They typically leave the body by passage in the urine stream. Many stones are formed and passed without causing any symptom in the body. These stones are common cause of blood in urine and often severe pain in the abdomen, groin and flank.
Data shows that one in every 20 people develops a kidney stone at some point in their life span. About 80% of those with kidney stones are men while 20% are women. Most commonly men experience their first episode between 20-30 years of age, while women experiences at their later age.
In India, the stones belt occupies parts of Gujarat, Punjab, Maharashtra, Delhi, Haryana and Rajasthan. In these regions, renal stone is so prevalent that most of the members of a family suffer from this disease sometime in their lives. Its prevalence is as high as 7.6% in Satpura region of Maharashtra, Gujarat, Madhya Pradesh and parts of Andhra Pradesh. It is also reported that a high and progressively increasing incidence of kidney stones in Udaipur and some other parts of Rajasthan.
In ancient civilization mankind is known to be suffering from urinary stone disease, which was found in tombs of Egyptian mummies dated 4800 BC and in the graves of north American Indians from 1500- 1000 BC. Buqrat (Hippocrates) in the 4th century BC, noted renal stones together with renal abscess and wrote it in the Hippocratic Oath as “I will not cut the stone”.
Unani Concept of Hasaat-e- Kuliyah (Nephrolithiasis)
According to Ali ibn-e- Sina (980-1037 AD), Kidney stone is formed by active power (Qoowat-e- Faayelah), which raises the temperature inside kidney. He also stated that stone producing matter / lithic matter (Maaddat-ul- Hisaat) is a viscous and sticky substance, may be either phlegm or viscous blood or pus. When expulsive power (Qoowat-e- Daafeá) of the kidney become weak due to altered temperament, hot inflammation or ulcer, then in spite of excreting out they retained in the calyces of kidney. Thus the lithic substance dried by the active power (Qoowat-e- Faayelah) of kidney to form crystal and gradually becomes stone.
Ali Ibn-e-Abbas Majoosi (930-994 AD) states, when more concentrated humours and highly viscous fluid adhere to the calyces of kidney, thus these humours and fluid dried by the high virulent temperature to form crystal and after some time gradually it results in stone formation. Jaleenoos (Galen) describes that, nephrolithiasis is mostly caused by the ulcer of the kidney, if pus is not passing out, it consolidates to form stone.
According to Ibn-e- Zohr (1091-1162 AD), when the kidney is unable to excrete out the thick humours due to its weakness, then these thick humours become deposited inside the kidney as a result of layer by layer crystallizations stone is formed.
According to Zakaria Razi (850-923 AD), the cause of this disease is abnormal humours and the body excretes the abnormal humor in the form of viscid fluid which moves towards the kidneys and form crests that cause the stone formation. Recurrence of stone formation is common.
Aetiology of Hasaat-e- Kuliyah (Nephrolithiasis) as per Modern Philosophy
As per modern philosophy, major risk factors responsible for the Nephrolithiasis/ kidney stone are inadequate urinary drainage, certain diets with excess intake of oxalates and calcium, certain microbial infections, vitamin abnormalities i.e.; excess intake of vitamin D, deficiency of Vitamin-A, certain metabolic diseases like gout, cystinuria, hyperparathyroidism, etc. apart from that intestinal dysfunction and environmental factors related to particular regions with hot and dry climatic conditions.
The anatomical structure of the upper and the lower tract might be contributing factor in predisposing an individual to urinary tract infection or stasis. The major anatomical abnormalities found were obstruction of the horseshoe kidney, ureteropelvic junction, incomplete or complete duplicated ureter, bifid pelvis, and medullary sponge kidney.
They all are known to be responsible for the formation of kidney stone. Increased rates of blood pressure and obesity, which are linked to urolithiasis, also contribute to an increase in the formation of stone.
Pathophysiology of Hasaat-e- Kuliyah (Nephrolithiasis) as per Unani philosophy
According to Unani philosophy, weakness of kidneys, viscous and thick humour, concentrated and sticky fluid, Su-e-Mizaj Kulyah (ill temperament of kidney), Waram-e- Kuliyah (nephritis), Qurooh-e-Kuliyah (kidney ulcer), weakness of expulsive power (Quwwat-e-Dafey’ah) of kidney and high virulent temperature are considered as potential causes for nephrolithiasis.
According to Unani medicine causes of stone formation in kidney is morbid matter (ghaleez madda) and stagnation of this morbid matter. This Morbid matter (Ghaleez madda) is produced by Ghaleez Aghzia e.g. concentrated milk, paneer, big birds (dhanek etc.) and meat of old camel, old bull, old goat, ghaleez meat, roasted meat and fish meat who has the properties of ghaleez and sangeen, roti (feteeri, leshdar, maida), kheer, sewayyan, and those food and fruits which are not easily digested as like raw apple, raw shaftaloo, seed of utaraj, seed of guava and also polluted water.
All these substances produce thick and viscous matter in the body, when the qoowat-e- haazima is weak so it leads to formation of morbid humour (ghaleez khilt) and pneuma (reeh). This pneuma (reeh) gets accumulated in the urinary tract. This matter (madda) remain in the kidney for long time; mainly because of weakness of kidney or weakness of its power of expultion which frequently develop consequent upon su-e- mizaj-e- kuliya or waram-e- har kuliya or qarha-e- kuliya. Under the influence of haraarat this ghaleez madda converted into gravel and gets expelled or stays back in the kidney and gets changes into stones.
Types of Hasaat-e- Kuliyah (Nephrolithiasis)
Going through the chemical composition, approximately 80% of stones are composed of calcium oxalate (Hisaat-e- Tootiyah) and calcium phosphate (Hisaat-e- Qaimooliyah). Out of these Calcium oxalate monohydrate (about 40-60%), Calcium oxalate dehydrate (about 40-60%), Calcium hydrogen phosphate (about 2-4%) Calcium orthophosphate (less than 1%). 10% of uric acid and urate stones (Hisat-e- Bauliyah) are composed of pure uric acid or ammonium/ sodium urate. 1% of struvite (magnesium ammonium phosphate produced during infection with bacteria that possess the enzyme urease). The remaining approximately 1% of cystine stone (Hisat-e- Zoobaniyah) contains sulphur. About 1% of Xanthine stone (Hisaat-e-Layyinah) is very rare.
Mixed Stones (about 50-60%); Mixed calcium oxalate-phosphate (about 35-40%) Mixed uric acid-calcium oxalate (about 5%) are very common.
Signs and symptoms of Hasaat-e- Kuliyah (Nephrolithiasis/ Renal stone)
Small sized urinary stones pass out of the body without any clinical intervention. Kidney stones greater than 5 mm almost always require urological intervention. Typical symptoms of acute kidney stones are intermittent colicky flank pain that may radiate to the lower abdomen or groin, often associated with nausea and vomiting. Haematuria, pyuria and burning micturition may be present. Lower urinary tract symptoms such as dysuria, urgency, and frequency may occur as the stone enters the ureter.
The hallmark of stones that obstruct the ureter or renal pelvis is excruciating, intermittent pain that radiates from the flank to the groin or to the genital area and inner thigh.
This particular type of pain, known as renal colic, is often described as one of the strongest pain sensations known to mankind. Renal colic caused by kidney stones is commonly accompanied by urinary urgency, restlessness, haematuria, sweating, nausea, and vomiting.
Management of Hasaat-e- Kuliyah (Nephrolithiasis)
Despite the invention of advanced technology like lithotripsy, the management of renal calculi remains a challenge for doctors. Most of the Indian patients prefer to take alternative medicine before undergoing painful surgical intervention.
The principles of management of Renal stone in Unani system of medicine is mainly through diuretic (Mudirr-e- baul) and lithotriptic (Mufattit-e- hisaat) drugs. These drugs make morbid and abnormal humours easily extractible from the body mainly through the excretory system.
Unani physicians recommends the management of kidney/ renal stone with drugs followed by surgical procedures, if patient is not relieved. Hippocrates is believed to have been the first person who recognized that high fluid intake increase urine volume and is favourable therapy for urinary disorders including kidney stone.
In Unani system of medicine the main aim of management for renal stone is to make abnormal and morbid humours easily extractible from the body through the excretory system. It is broadly involved the three types of therapy which are as follows.
A) Ilaj- bil- Ghiza (Dietotherapy)
In this way of treatment, plenty of fluid and easily digestible foods like Aab-e- Naryal (coconut water), Choozah (chick),Gazar (carrot), Karela (bitter guard), Nashpati (pear), Jau (barley), Himsiyah (gram), Magz-e- Badaam (Almond), Khushkari Nan (non-leavened chapati), Teehu, Qalb-e-Ghenam (goat‟s heart) and Asaafeer (sparrow) should be used.
High quantity oxalate containing diets such as Cholayi (Amaranth leaves), Asfanakh (Spinach), Amlah (Emblica Myrobalan), Tamatar (Tomato), Kaju (Cashew nut), Cheekoo (sapodilla), Kheyar (Cucumber) and uric acid containing diets such as kadu (Pumpkin), Mushroom, Phool Gobhi (Cauliflower), Baigan (Brinjal) should be avoided.
Similarly hard and late digestible diets like meat, milk, mutton, Maidah ki Roti, Fateeri Roti, guava and apple to be avoided.
B) Ilaj- bil- Tadbeer (Regimenal Therapy)
The basic aim of Ilaj-bil- Tadbeer (Regimenal Therapy) is softening the disease matter (Talteef-e- Maddah) and resolving the disease matter (Taqtee-e- Maddah). For this purpose, patient is instructed to vomit out and to use of mild Purgatives (Mushilat) like Anjeer (Ficus carica), Sapistan (Cordia latifolia), Khatmi (Althoea officinalis seed), Aslussoos (Glycyrrhiza glabra), Turanjabeen (Alhagi maurorum Baker Dexv / Alhagi pseudalhagi (Biedb.) Desv./Alhagi camelorum) and Maghz-e-Amaltas (Cassia fistula)).
Alogwith purgative drugs, some Diuretics (Mudirrat) with such medicines not having excess hot temperament like Tukhm-e-Kadu (Cucurbita moschata (Duchesne) Poir.), Tukhm-e-Khyarain (Cucumis sativus & Cucumis melo seeds), Kaknaj (Physalis alkekengi), Haliyoon (Asparagus officinalis), Khar-e- Khasak (Tribulus terristris), Persiyao Shan (Adiantum capillus- vereris) also used.
Fasad (Venesection) should be done on Rag-e- Basaleeq (Baselic Vein) when the severe pain arises, only if the patient has abundant blood. Huqna (Enema) of Mulayyin & Muzliq (laxative and emollient) like Tukhm-e- Khatami (Althoea officinalis), Tukhm-e- Katan (Linum usitatissimum), Aspaghol (Plantago ovata Forsk.) as well as Murakhkhi wa Mudir (slackent & diuretic) like Khurfah (Portutaca oleracea Linn.), Bekh-e- Kibr (Capparis spinosa), Persiyao Shan (Adiantum capillus-vereris) are advised to the patient in constipation.
If obstructive uropathy developed, Huqna (Enema) of Muzliq Lu‟aab (emollient mucilage) like Lu’aab tukhm-e- Khatami (Althoea officinalis), Lu’aab Kataan (Linum usitatissimum Linn.), Lu’aab Hulbah (Trigonella foenumgraecum) given to the patient, and Roghan-e- Baadam (Almond Oil) with Maghz-e- Amaltas (Cassia fistula) orally also.
Aabzan (Sitz Bath) to relieve the pain, in the decoction containing Musakkin wa Murakhkhi (sedative & slackent) drugs such as Baboona (Maticaria chamomilla), Khatami (Althoea officinalis), Shibt (Anethum sowa kutz.), Karafs (Apium graveolens), Persiyao Shan (Adiantum capillus- vereris), Hulbah (Trigonella foenum- graeceu),, Qurtum (Carthamus tinctorius), Bekh-e- Kibr (Capparis spinosa), Aspaghol (Plantago ovata Forsk.), Khurfah (Portutaca oleracea), Banafshah (Viola odorata), Barg-e- Kunjad (Sesamum indicum Leaves) should be taken by the patient for a few period.
If Mudirrat (diuretics) mixed with the above decoction, the effectiveness is much higher.
After Sitz Bath (Aabzan) Roghan-e- Soya (Dill Oil), Roghan-e- Kheri, Roghan-e-Banafshah (Violet herb Oil) should be applied on groin of the patient locally.
C) Ilaj-bil- Dawa (Pharmacotherapy)
In this form of treatment the recommended principles of treatment is to control stone formation (nephrolithiasis) and to expel out the destroyed stones form the body.
According to above philosophy Mufattit-e- Hisat (Litholytic/ Lithotriptic), Mudirr-e- Baul (Diuretic), Mohallil-e- Waram (Resolvent) along with Muqawwiyat-e- Kuliyah (Nephroprotective) drugs are used in Unani system of medicine.
Considering above mentioned pharmacological properties, the Unani drugs to be prescribed in renal stone/ nephrolithiasis are described below.
Unani Advia-e-Mufradah (Single Unani Drugs)
Unani Advia-e- Murakkabah (Compound Pharmacopeial Formulations)