Su’al Qiniya: Exploring Its Unani/Persian Foundations and the Discourse on Anemia Correlation

Introduction

Su’al Qiniya, a condition well-documented in Unani/Persian medicine, has fascinated scholars and practitioners for centuries. The term Su’al Qiniya is derived from two Arabic words, ‘Su’ meaning defect and ‘Qiniya’ meaning treasure or assets. Thus, it suggests an alteration or deficiency in the body’s storage mechanisms. (Nasar, 2024, pp. 7-11) Described under various terminologies such as Fasad-e-Mizaj (impaired temperament) and Sue Mizaj (morbid temperament), Su’al Qiniya embodies a complex interplay of temperamental imbalances, particularly within the liver. (Baghdadi, 2004, pp. 286-287; Aljurjani, 2010, pp. 414-415)

Despite the rich historical and philosophical context provided by Unani scholars like Al-Jurjani, Ibn-e-Sina, and Baghdadi, understanding of this condition in its entirety remains a challenge. In contemporary medicine, Su’al Qiniya is often correlated with anemia, a condition characterized by a deficiency of red blood cells or haemoglobin. (Ahmad, et al., 2020, pp. 38-51; Zulkifle, Ahmad, and Ansari, 2020, pp. 22-24; Khan, et al., 2024, pp. 41-45) Some scholars argue that it is misinterpreted as anemia and is, instead, a nutritional problem. (Pourhosseini, et al., 2019, pp. 130-135)

This article aims to explore the basis of this correlation and examine whether Su’al Qiniya can be equated with anemia or not. By delving into classical Unani literature and comparing it with modern medical insights, we seek to bridge the gap between traditional and contemporary understandings of this enigmatic condition.

Methods

This review was conducted using an integrative approach combining classical Unani literature with contemporary biomedical research to explore the concept of Su’al Qiniya and its possible correlation with anemia. Primary sources included authoritative Unani texts such as Al Qanoon fit tib (Avicenna), Zakhira Khwarzam Shahi (Aljurjani), Kamil-us-Sana (Majoosi), Tib-e-Akbar (Akbar Arzani), Kitab-al-Mukhtarat fi- Tib (Ibne Hubal Baghdadi) for the concept of Su’al Qiniya. Various books of Kulliyat such as Kulliyat-e-Qanoon (Kabiruddin), Kulliyat-e-Nafisi (Kabiruddin), Kitab-Al-Miyah (Masihi), Kitab-al-Kulliyat (Ibne Rushd) were referred to understand the principals of erythropoiesis/haematopeisis in Unani. Secondary sources included WHO and CCRUM terminologies on Unani/Persian medicine, as well as modern interpretations of hepatic and hematological disorders. Contemporary biomedical literature was searched in PubMed, Google Scholar, Scopus, and AYUSH Research Portal using keywords: Su’al Qiniya, Fasad-e-Mizaj, Sue Mizaj, Zoaf-e-Jigar, anemia, Unani/Persian medicine, Faqr-ul-dam etc. Relevant data were systematically extracted and categorized under the following themes: Conceptual definitions of Su’al Qiniya in Unani texts, Etiology and pathogenesis based on Unani principles, Mechanisms of blood formation (Tauleed-e-Khilt-e-Dam), Comparative features between Su’al Qiniya and anemia in modern medicine.

Cross-referencing between Unani and modern perspectives was used to identify conceptual overlaps and distinctions. All classical references were verified through authentic editions and peer-reviewed translations to ensure reliability.

Traditional Unani Concept of Su’al Qiniya

According to Unani philosopher Ibn-e-Sina, “Su’al Qiniya is a condition of altered Mizaj of the liver, upon which Zoaf supervenes; it is an early symptom of Istisqa and is termed as Fasad-e-Mizaj.” (Avicenna, n.d., pp. 854-885) Both Baghdadi and Al-Jurjani presented similar views, with Al-Jurjani also referring to it as Su-e-Mizaj. (Baghdadi, 2004, pp. 286-287; Aljurjani, 2010, pp. 414-415) However, Hakeem Akbar Arzani attributes Fasad-e-Mizaj solely to Zoaf-e-Jigar. (Arzani, n.d., p. 458) Although the alteration of temperament is not specifically mentioned but is well understood as Su-e-Mizaj Jigar Barid (cold morbid temperament of liver) from the disease presentation itself. (Baghdadi, 2004, pp. 286-287; Avicenna, n.d., pp. 854-885; Tabari, 1997, pp. 202-205; Tabari, 2010, p. 126)

In WHO international standard terminologies on Unani/Persian medicine, Su’al Qinya is defined as inability of liver to produce normal humours; a morbid state caused by deranged temperament of liver whose debility is characterized by pallor and oedema of extremities. (WHO International Standard Terminologies on Unani Medicine, 2023) While according to Standard Unani Medical Terminology (CCRUM), its possible English equivalent is anemia with hypoproteinaemia. (Standard Unani Medical Terminology, 2012, p. 224)

This condition manifests as pallor or yellowish discolouration of body, swelling over eyelids, face, scrotum and peripheral body parts, sometimes it spreads all over the body (anasarca) and appears as pitting oedema: laziness and lethargy, fasad (disruption) of all the four hazam (digestion), namely hazam-e-medi (gastric digestion), hazam-e-kabdi (hepatic digestion), hazam-e-uruqi (vascular digestion), hazm-e-uzwi (organ digestion), good appetite in spite of poor digestion, changes in bowel habit (altered by constipation and regular bowel movements), disturbed sleep cycle (altered by sound sleep and insomnia), oliguria, hyperhidrosis, flatulence, delayed wound healing, burning and itching sensation in gums due to ascent of bukharat (vapours) from liver, with development of boils. (Aljurjani, 2010, pp. 414-415; Avicenna, n.d., pp. 854-885; Khan, 2011, pp. 519-522; Majoosi, 2010, pp. 520-522)

Etiology and Etiopathogenesis of Su’al Qinya

Su’al Qiniya, as described in classical Unani literature, has a multifaceted aetiology. The main contributing factors include: Zoaf-e-Jigar (hepatic insufficiency), Sue mijaz/Fasad-e-Mizaj jigar (Altered temperament of liver), dominance of burudat (cold) or hararat (heat) in the liver, Zoaf-e-Meda (gastric debility) or Fasad-e-Meda (gastric impairment), Amenorrhoea and cessation of bleeding from haemorrhoids, Menorrhagia and excessive bleeding from haemorrhoids. This indicates the complexity of its pathology, where seemingly opposite conditions contribute to the same outcome. Also, Malankhuliya miraqi (melancholia due to involvement of gut) where saudawi bukharat (vapours black bile) ascends towards liver and exposure to polluted air are considered as contributing factors. (Baghdadi, 2004, pp. 286-287; Aljurjani, 2010, pp. 414-415; Avicenna, n.d., pp. 854-885; Khan, 2011, pp. 519-522; Majoosi, 2010, pp. 520-522)

The underlying pathology of Su’al Qiniya involves a complex interplay of these factors. Ibn-e-Rushd explains that a decline in the liver’s Quwwat-e-Hazima (digestive faculty) due to Zoaf-e-Jigar results in the production of balghami khoon (phlegmatic blood). This phlegmatic blood, while nourishing the body organs tends to divert their normal temperament towards a phlegmatic temperament causing istisqa-e-lahmi (oedema). This decline of action is attributed to Sue-Mizaj Barid Maddi or Ghair Maddi (cold or inappropriate temperament). (Rushd, 1987, pp. 105-111)

Moreover, Spleenomegaly or spleen inflammation impairs the spleen’s ability to purify blood from sawda (black bile). This black bile accumulates in the liver and being cold in temperament extinguishes its heat. Excessive blood loss from wounds, menstrual bleeding, or rectal bleeding alters the liver’s temperament to burudat (coldness) by reducing its blood content which is the source of heat in liver, contributing to Su’al Qiniya. (Majoosi, 2010, pp. 520-522)

The cessation of menstrual bleeding or habitual bleeding from haemorrhoids causes blood retention in the liver, further extinguishing its hararat-e-ghariziya (innate heat) and causing coldness. Burudat-e-Meda (coldness of the stomach) affects the temperament of ingested food, transforming it to cold, which is then transferred to the liver. Incomplete digestion of kailoos (chyme) in the stomach leads to burudat-e-jigar (coldness of the liver). (Majoosi, 2010, pp. 520-522)

Finally, obstruction by Akhlat-e-Balghami (phlegmatic) and lazij (sticky) materials in the liver’s vessels restricts the movement of hot air and blood flow, contributing to coldness and affecting overall liver function. (Majoosi, 2010, pp. 520-522)

In summary, the diverse aetiological factors, whether through direct or indirect mechanisms, lead to a cool alteration in the liver’s temperament, which is central to the pathology of Su’al Qiniya.

Hence, an altered liver temperament, or Sue Mizaj Barid, interferes with hepatic digestion, where nutrients transform into raqeeq mai khoon (dilute watery blood). This dilute blood disrupts tertiary (vascular) digestion and impairs fourth digestion in organs. As a result, it is unable to become mushabeh badan (similar to organ) and stick to it. So, this raqeeq mai khoon gets collected in interstitial spaces, resulting in the development of oedema. (Rushd, 1987, pp. 105-111)

In contemporary practice, many Unani scholars and practitioners identify Su’al Qiniya as a form of anemia, primarily because both conditions share similar clinical features, such as pallor, fatigue, general weakness, delayed wound healing, and oral ulcers. However, to fully understand this correlation, it is essential to delve into the Unani concept of Tauleed-e- Khilt-e-Dam (blood synthesis).

Synthesis of Khilt-e-Dam (Blood): Unani Concept

In Unani/Persian medicine, the Akhlat-e-Arba (four humors) of the body are synthesized in the liver from the Ghiza (food) we consume. This process begins even before the food reaches the liver (centre for production of humors). Initially, digestion starts in the oral cavity, aided by mastication and hararat-e-Ghariziya (innate heat) of saliva. Once the food enters the stomach, it is further processed under the influence of the stomach’s heat and the heat from adjacent organs like the liver and heart. This results in the formation of kailoos (chyme), which is absorbed through the Urooq-e-Masariqa (mesenteric arteries) and transported to the liver via t Babul Kabid (portal vein). (Kabiruddin, 1934, pp. 59-62)

Within the liver, the food undergoes nuzuj (concoction), which separates different byproducts: Safra (bile) and Sawda (black bile). Some of the partially digested food remains as Balgham (phlegm), while the purified portion is converted into Khilt-e-Dam (blood). Initially, this blood is raqeeq (dilute) due to excess water, which is later absorbed by the kidneys. The remaining blood with desired consistency is circulated throughout the body to meet the nutritional requirements of various organs. (Kabiruddin, 1934, pp. 59-62)

There are Four key factors which influence the synthesis of blood which are as follows: (Kabiruddin, n.d., pp. 59-62; Masihi, 2008, pp. 101-112)

i. Sabab-e-Faili: The innate heat of the liver (Hararat-e-Motadilah)

ii. Sabab-e-Maddi: The nutritional content of food and drink

iii. Sabab-e-Soori: Proper concoction of food (Nuzuj)

iv. Sabab-e-Tamami/Ghai: The process through which organs derive nutrition from the liver.

Any disruption in one or more of these factors can lead to the production of ghair tabai khoon (altered blood).

Ali Ibn-e-Abbas Majoosi further elaborates that the conditions affecting the Quwwat-e-Muwallid-e-Khoon (blood-forming faculty) often lead to diseases like Istisqa (ascites). This impairment can occur in several ways:

i. Burudat-e-Jigar (coldness of the liver), which directly weakens the liver’s blood-forming function.

ii. Diseases in nearby organs, such as the stomach or intestines, which interfere with the absorption of ghiza into the liver.

iii. Sawdawi obstructions in the liver’s vessels, preventing the proper flow of heat and blood, causing further coldness and dysfunction in blood production.

Majoosi also noted that excessive coldness in the liver results in whiteness of the blood, reflecting an imbalance in its synthesis. (Majoosi, 2010, pp. 520-522)

In modern medicine, nutritional deficiencies, malabsorption, and metabolic disturbances are well-recognized causes of anemia. However, according to Unani philosophy, it is evident that the maintenance of the liver’s hot temperament is critical for proper blood synthesis. When this innate heat diminishes blood production is impaired, potentially leading to anemia.

Conclusion

After reviewing the literature, it is evident that traditional Unani scholars consistently emphasized that Su’al Qiniya stems from an alteration in the liver’s temperament. It is regarded as Muqadama Istisqa (preliminary stage of ascites) and signifies early-stage liver disease, which, if left untreated, can progress to ascites. In contrast, anemia typically does not present with edema unless it is severe, nor does it directly cause ascites unless it is associated with conditions, such as liver, kidney, or heart disease, where ascites and anemia may coexist.

According to Unani philosophy, Su’al Qiniya shifts the liver’s temperament towards coldness, which can contribute to the development of anemia as a symptom or complication. This highlights that, while anemia may appear alongside Su’al Qiniya, the two should not be equated.

In conclusion, Su’al Qiniya is fundamentally a liver disorder rooted in the Unani concept of Su’al Mizaj (alteration of temperament). Therefore, it should be understood, diagnosed, and managed within its unique Unani framework, rather than being directly correlated with conventional medical conditions like anemia.

Authors’ Contribution

Faseeha Eram contributed to the conception and design of the study, data acquisition, analysis and interpretation, and preparation of the original manuscript. Mohammad Aleemuddin Quamri, Afshana Nabi, and Zebaakthar R. Sayyed contributed to the review and editing of the manuscript for important intellectual content. All authors read and approved the final version of the work.

Funding

None.

Conflict of Interest

None.

References

1. Ahmad, R., et al., 2020. Su-ul-Qinya and Their Clinical Correlation with Anaemia. American J Pharmacy and Health Research, 8(8), pp. 38–51. Available at: https://doi.org/10.46624/ajphr.2020.v8.i8.004.
2. Aljurjani, A.A., 2010. Zakhira Khwarzam Shahi. Translated from Urdu by H. Hadi Hussain Khan. New Delhi: Idara Kitab-us-Shifa.
3. Arzani, A., n.d. Tib-e-Akbar. Translated from Urdu by H.M. Hussain. Deoband: Faisal Publications.
4. Avicenna, n.d. Al Qanoon fit Tib. Translated from Urdu by Hakeem G.H. Kantoori. New Delhi: Idara Kitab-us-Shifa.
5. Baghdadi, I.H., 2004. Kitab-al-Mukhtarat fi- Tib. Translated from Urdu by CCRUM. New Delhi: CCRUM.
6. Kabiruddin, H.M., n.d. Kulliyat-e-Qanoon. Translated from Urdu by Abu Bakar Siddiq. Lahore: Sheikh Muhammad Basheer and Sons.
7. Kabiruddin, H.M., 1934. Kulliyat-e-Nafisi. New Delhi: Idara Kitab-us-Shifa.
8. Khan, A.A., et al., 2024. Safty and Efficacy of a Polyherbal Unani Formulation (Sharbat-e-Faulad) in Sū’ al-Qinya (Aaemia) - A Multi Centric Study. Int J Advance and Innovative Research, 6(2), pp. 41-45.
9. Khan, M.A., 2011. Aksee-re-Azam. Translated from Urdu by Allama Kabiruddin. New Delhi: Idara Kitab-us-Shifa.
10. Majoosi, A.I.A., 2010. Kamil-us-Sana. Translated from Urdu by Ghulam Hasnain Kantoori. New Delhi: Idara Kitab-us-Shifa.
11. Masihi, A.S., 2008. Kitab-Al-Miyah. Translated from Urdu by CCRUM. New Delhi: CCRUM.
12. Nasar, M.K., 2024. A literary review on Su -al- Qinniya (Anaemia) and its management. Endocrinol Metab Int J, 12(1), pp. 7–11. doi: 10.15406/emij.2024.12.00338.
13. Pourhosseini, M., et al., 2019. Misinterpret of a unique clinical presentation named “Soo ul qinya” in Traditional Persian medicine with “Anemia”. Int J Ayurvedic Medicine, 10(2), pp. 130–135.DOI
14. Rushd, M.I., 1987. Kitab-Al-Kulliyat. New Delhi: CCRUM. [in Urdu].
15. Standard Unani Medical Terminology, 2012. New Delhi: CCRUM. Available at: https://ccrum.res.in/writereaddata/UploadFile/Standard%20Unani%20Medical%20Terminology_1430.pdf. [Accessed 10 September 2024]
16. Tabari, A.I.R., 2010. Firdaus Al-Hikmat. Translated from Urdu by H. M. Awwal Shah Sumbhali. New Delhi: Idara Kitab-us-Shifa.
17. Tabari, A.H.A.B.M., 1997. Al-Moalajat-al-Buqratiya. Translated from Urdu by CCRUM. New Delhi: CCRUM.
18. WHO International Standard Terminologies on Unani Medicine, 2023. 1st ed. Geneva: World Health Organization.
19. Zulkifle, M., Ahmad, S., and Ansari, T.H., 2020. Efficacy of Tab Damvi and Syrup Jigreen in Su al-Qiniya (Anaemia) - A Case Report. Int J Research and Review, 7(5), pp. 22-24.