Categorization of Functional Constipation in Traditional Persian Medicine

Materials and Methods

Eligible patients were males and females aged 18 to 65 years and diagnosed with functional constipation according to the Rome III criteria ²⁵ by a gastroenterologist. Patients were excluded if they met criteria for irritable bowel syndrome with constipation or if they had structural bowel disease or constipation secondary to other diseases or medications. Other major exclusion criteria included current laxative, history of gastrointestinal surgery (except appendectomy and cholecystectomy), active anal fissure, and pregnant/lactating women.

We evaluated 110 patients with functional constipation who were referred by the gastroenterologist. The evaluation was done via clinical history and examination by a well-educated doctor of traditional medicine. Categorization was based on visual scales, signs, and symptoms (rated from 0 [never] to 2 [most of time]), including the following:

Digestion assessment

Results

From December 2013 to October 2014, of 172 patients who visited with complaints of constipation, 128 patients with functional constipation were referred by the gastrointestinal clinic. Sid of the participants were excluded (2 had eating disorders and 4 because of ongoing usage of proton pump inhibitor, H₂ receptor antagonist consumption), and 12 participants refused to answer the questions. Majority of the referred patients (70.9%) were females, and only 29.1% were males. Among the participants, 43.6% were <40 years of age and 48.2% were aged between 40 and 59 years. The most common presenting complaints included weak digestion (84.5%), bloating (67.3%), dry mouth (65.4%), borburygmus (60%), thirst (45.5%), and takhazkhoz (33.6%). Hose or finger was used to exit stool in 49 patients, which was more prevalent among females. Fifteen case had anorexia and they were all young females. Overall, 24 patients (22%) reported frequent belching and sour odor burping, and 10 cases complained of sour taste of the mouth in the morning. None of the visiting patients in study reported acholic stool or smoky smelling belching. Table 1 shows the prevalence and severity of gastrointestinal symptoms and signs in patients with functional constipation.

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Table 1.

The Prevalence and Severity of Gastrointestinal Symptoms and Signs in Patients With Functional Constipation.

Age (years)		20-29	30-39	40-49	50-59	≥60
Dry mouth	Mild	9 (8.2%)	15 (13.6%)	12 (11%)	4 (3.6%)	5 (4.5%)
	Severe	5 (4.5%)	2 (1.8%)	6 (5.4%)	10 (9%)	4 (3.6%)
Thirsty	Mild	7 (6.4%)	15 (13.6%)	12 (11%)	4 (3.6%)	2 (1.8%)
	Severe	4 (3.6%)	3 (2.7%)	2 (1.8%)	1 (0.9%)	0
Takhazkhoz	Mild	8 (7.3%)	7 (6.4%)	5 (4.5%)	5 (4.5%)	2 (1.8%)
	Severe	6 (5.4%)	1 (0.9%)	2 (1.8%)	2 (1.8%)	0
Bloating	Mild	3 (2.7%)	14 (12.7%)	3 (2.7%)	7 (6.4%)	5 (4.5%)
	Severe	10 (9%)	7 (6.4%)	16 (14.5%)	9 (8.2%)	0
Borburygmus	Mild	8 (7.3%)	7 (6.4%)	10 (9%)	5 (4.5%)	2 (1.8%)
	Severe	10 (9%)	9 (8.2%)	7 (6.4%)	7 (6.4%)	1 (0.9%)
Weak digestion	Mild	7 (6.4%)	5 (4.5%)	9 (8.2%)	4 (3.6%)	5 (4.5%)
	Severe	10 (9%)	19 (17.3%)	17 (15.4%)	14 (12.7%)	3 (2.7%)
Sour taste, mouth		2 (1.8%)	4 (3.6%)	3 (2.7%)	2 (1.8%)	1 (0.9%)
Sour taste, belching		0	2 (1.8%)	3 (2.7%)	3 (2.7%)	2 (1.8%)
Frequent belching		3 (2.7%)	0	6 (5.4%)	4 (3.6%)	1 (0.9%)
Decreased appetite		8 (7.3%)	5 (4.5%)	2 (1.8%)	0	0
Hose or digital evacuation		9 (8.2%)	13 (11.8%)	14 (12.7%)	11 (10%)	2 (1.8%)
Much saliva mouth		3 (2.7%)	6 (5.4%)	3 (2.7%)	0	2 (1.8%)

The final decision and determination were made by a traditional clinician. All patients were categorized into 7 main diagnoses, as mentioned earlier. The final categorization is described in Figure 1. Almost two thirds (60%) of the patients with constipation had mild to severe cold distemperament of the gastrointestinal system. Signs and symptoms of almost half of the patients (49%) were compatible with dry distemperament of the gastrointestinal tract. Weak repulsion power and increase of melancholic humor constituted 44.5% and 17.3% of diagnoses, respectively. A further 13.6% of the patients were categorized as low eating. Among the patients, 13 did not have any specific gastrointestinal complaints, or had mild complaints, so they were not classified.

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Figure 1.

Categorization of patients with functional constipation according to causes in traditional Persian medicine.

It should be noted that a patient may be listed in more than one category; for example, a patient with weak repulsion power may have intestinal cold distemperament symptoms or low eating.

Discussion

Surprisingly, none of the participants of the study had warm distemperament. Moreover, none of the patients were diagnosed to have biliary duct obstruction or reduced bile production.

Considering the causes for abnormal excretion ability, among the 49 patients who used manual maneuvers for purging, 61% had history and physical examination in favor of cold distemperament, and 20% had increased gastrointestinal moisture. For the other patients, no specific causes were determined. In the current study, among the participants with lack of appetite, some had symptoms of abnormal phlegm and black bile humor.

From the perspective of traditional Persian medicine, several causes have been considered for loss of appetite. For instance, heat has been considered as a cause, which exerts its effect on the appetite by relaxation of the gastric fibers at this region, similar to what happens in fever, and this effect varies based on the severity of heat. Moreover, any abnormal humor in the gastroesophageal junction that prevents the effect of black bile causes loss of appetite. In this regard, presence of abnormally high levels of black bile or phlegm in the gastroesophageal junction causes loss of appetite. The symptoms of abnormal phlegm in the stomach are bloating, sour belching, nausea, decreased appetite, and not feeling thirsty. ¹⁸ According to sages of traditional medicine, the causes of diseases must be eliminated. So, as a first step, the following measures are recommended ^{18 –21} :

Avoid foods that increase dryness of bowels such as fried foods, beef, oak, millet (Panicum miliaceum), and high consumption of rice

The following foods are beneficial: laxative foods such as porridge and soup including chicken, pigeon, and sparrow porridges; prune soup; fatty gruel made of bran, sugar, and oil; and fruits such as plums, apricots, and peaches.

Based on the cause of disease, some treatments have been recommended: In cases where the distemperament cause is the cold and dry (sauda) temper of the intestines, cathartic compound drugs for sauda temper, such as cuscuta, Epithymum, and Polypodium vulgare compounds, should be used. Borage distillate (Borago officinalis) or lemon balm (Melissa officinalis) is also helpful instead of having water.

If the distemperament cause is decline in the flow of bile into the intestines, rubbing cow butter or olive oil on the abdomen and the use of pennyroyal suppositories (Mentha pulegium) and honey or lily root (lilium) are recommended.

Where the disease cause is extreme intestinal heat and drought, drinking violet syrup (Viola odorata), lily syrup (Ipomoea tricolor), manna (Alhagi pseudoalhagi), pumpkin juice (Cucurbita pepo), and the juice of purslane seed (Portulaca oleracea) are helpful. Daily consumption of psyllium (Plantago oleracea) to relieve dry distemperament of bowels is another treatment. The use of nutritious and restorative oils such as Qest oil (installment or Kvshnh) and Bydanjyr (castor oil) on abdomen and pelvic to strengthen the repulsion strength and the muscles of these areas are useful.

In cases where distemperament cause is cold temper colons, using anisette distillate (fennel) and rose water or honey instead of water and adding spices such as cinnamon (Zeylanicum cinnamomum), ginger (Zingiber officinale), and mint to patients’ foods may help.

To improve appetite in patients who suffer from loss of appetite, mint syrup and Skanjebin Sefrejly (a mixture of matured quince juice [Cydonia oblonga] and mildly boiled honey and vinegar to have a honey-like form) are recommended. As mentioned earlier, none of the patients met the criteria for warm distemperament, while 53.3% of them had abnormal phlegm and 20% considered permanent bloating (increased level of black bile humor). However, this was not the case for 2 patients among those with this diagnosis.

As the results showed, most patients with some degrees of moderate to severe dry distemperament were young. This can be due to the higher frequency of taking dry foods such as chips and fast foods or due to higher physical activity or less sleep. In traditional Persian medicine, sleep is considered as calmness and awakening is regarded as movement. It is believed that calmness leads to higher moisture in the body while physical movement leads to waste of the moisture and as a result causes dryness. This is where insomnia affects the digestion process as it is believed that the digestion process is completed during sleep. ^18,25

So far, functional gastrointestinal disorders cannot be completely explained by biochemical or anatomical phenomena. ²⁵ In the Canon of Medicine, in the chapter on gastrointestinal diseases, Avicenna explains that an individual has distemperament when the digestive system does not completely fulfill its function, and it is not caused by ulcer or the food taken. ¹⁸ It seems that this definition comprises the description currently used in modern medicine for functional disorders.

Since in modern medicine temperament is not taken into account for the development of gastrointestinal disorders, it is suggested to carry out studies on functional gastrointestinal disorders based on the temperaments. In the current study, most patients with functional constipation had cold temperament of the gastrointestinal system, which can be due to not observing the basics of eating and drinking according to the traditional Persian medicine; for instance, drinking water before, during, or just after taking food; when fasting in the morning; immediately before exercise or physical activity; after taking bath; or after having intercourse. Other examples could be taking foods with different digestive properties in one meal. Also, prevention of defecation and gas passing is very bad and harmful, particularly in constipated patients. Continuing any of the above-mentioned practices would influence the digestion in a negative manner and consequently lead to problems and dysfunction of the gastrointestinal system. ^18,20 So these principles should be followed.

Conclusion

High prevalence of distemperaments of the gastrointestinal system in constipated patients shows that management of distemperaments can be used for the treatment of functional constipation. This project is a novel study that provides the opportunity for investigating epidemiological aspects of these distemperaments and their relationship with functional constipation. Furthermore, it gives us the opportunity to investigate the presumable role of lifestyle and nutritional factors in functional constipation symptoms and their severity.