DIAGNOSIS FROM THE STOOL
The Alvine Discharge
In Greek Medicine, diagnosis can also be done by examining the stool, which is called the Alvine Discharge. Usually, general questions about the patient's stool and bowel habits are asked in the medical history, but when actual examination is needed, the physician will ask the patient to bring a stool sample in for inspection.
Both the urine and the stool can be examined to yield valuable diagnostic information, but traditionally, examining samples of the patient's urine is done more frequently than examining the stool. When traditional methods of simple visual examination of the stool are insufficient, the contemporary practitioner of Greek Medicine will have modern lab tests of the stool for things like ova and parasites, or occult blood, done.
The patient is asked to collect a sample of his/her stool in a small glass jar or plastic container. The container must be clean, and have a tight, securely fitting lid. Besides being examined visually, the sample is also smelled for odor and probed with an instrument to examine its basic hardness, consistency and texture as well as checking it for the presence of any undigested food or foreign matter.
The Physiology of Defecation
The stool is the principal waste product of the First Digestion, which occurs in the gastrointestinal tract. After the chyle, or creamy juice essence of the food, is extracted and absorbed in the intestinal tract, the unusable waste that remains forms the stool. And so, examination of the stool yields the most information about the nature, temperament and overall quality of the initial First Digestion of food and drink in the GI tract.
In its trip down the GI tract on its way to becoming the stool, the semi-liquefied food juices are acted on by the Four Humors, which are products of the Second Digestion, which happens in the liver. Each one of these humors has its own inherent force, or Administrative Virtue, which determines how it acts upon the semi-liquefied food juices in the formation and expulsion of the stool. For normal, healthy defecation, all the Four Humors must be working harmoniously together in the right balance or proportion.
Blood, or the Sanguine humor, has an Attractive force, or virtue. Blood running through the fine capillaries in the villi of the small intestine attracts, or draws in, nutrients from the chyle into itself, and is responsible for the initial absorption of raw nutrients, which are sent to the liver for processing into the Four Humors. Blood also carries the vital principles that power the functioning of the peristaltic muscles that propel the food juices or bolus along on its way towards becoming the stool.
Phlegm, or the Phlegmatic humor, has an Expulsive force, or virtue. Phlegmatic secretions of the GI mucosa act as a lubricant, smoothing the peristaltic flow of the food juices or bolus along its way towards defecation. A sufficient quantity of fluids, or the Water element, must remain in the stool to give it the necessary softness that makes defecation possible. The normal, healthy stool is not purely solid, but rather semi-solid. If we don't adequately feed the Phlegmatic humor with sufficient fluids and juicy, moist fresh fruits and vegetables, we will get constipated, and find proper stool expulsion difficult.
Yellow bile, or the Choleric humor, has a Digestive force, or virtue. It is secreted by the liver and gall bladder directly into the duodenum and small intestine. Its main job there is to excrete, digest and absorb fats, but its hot, sharp, mildly irritating quality also acts to stimulate peristaltic movement and the defecation reflex in the large intestine. This makes bile the body's own natural laxative. Normal healthy bile is what colors the stool a rich, dark brown; stools that are too light in color usually lack sufficient bile.
Black bile, or the Melancholic humor, has a Retentive force, or virtue. The action of black bile, with its drying quality and Retentive force, works to reabsorb vital fluids and solidify the stool in the large intestine. Black bile gives the stool the necessary solidity that enables it to be retained until the time is right for defecation. Excessive amounts of black bile, however, lead to excessive retention, or constipation.
Stool formation and defecation is the main function of the large intestine. Phlegm softens and lubricates the stool, favoring expulsion. Black bile condenses and solidifies the stool, favoring retention. Into this delicate balance steps yellow bile, which tips the scales in favor of defecation.
Stool Patterns of the Four Temperaments
Each of the Four Temperaments has typical stool patterns and bowel habits associated with it, according to the nature of its predominant humor. In addition, acquired conditions and disorders affecting the stool can be broadly differentiated according to the classical concepts of humor and temperament. For each of the Four Temperaments, I will first discuss the typical patterns and tendencies of the normal individual, and then I will discuss some common acquired conditions and disorders pertaining to that humor and temperament.
Sanguine (Warm and Moist): Since Sanguine is considered to be the most equable and balanced of all the temperaments, its stool patterns and bowel habits are also generally the most healthy and desirable. The Sanguine stool has adequate, generous bulk; has the perfect balance between softness and firmness, and is well-formed; has a rich brown color, and no unpleasant odor.
Some say that, because blood is the predominant humor in the Sanguine temperament, that the Sanguine stool frequently has a reddish tint. But any presence of blood in the stool is abnormal and pathological. Bleeding from the colon and rectum will show up as red blood leeching out from the stool, and bleeding from higher up in the GI tract will often show up as tarry patches in the stools; or, the blood may be hidden, or occult. Certain foods, like beets, can also color the stool a bloody red.
Those of a Sanguine temperament have a predilection for overeating, eating rich food, and not getting adequate fiber. Food that is too nutrient dense and fiber poor will tend to stagnate, ferment and putrefy in the digestive tract and bowels. There will be abdominal bloating, sluggish bowels, constipation, foul smelling gas and flatulence, and stools that are soft, gummy and foul smelling. Putrefaction is basically a Sanguine condition of excess warmth and moisture.
Medical recognition of the importance of fiber is nothing new. Over two thousand years ago, Hippocrates praised the health benefits of fiber.
Phlegmatic (Cold and Wet): The typical Phlegmatic stool is large, copious and soft, indicating the presence of excess phlegm and dampness. There is no strong or offensive odor. The texture of the normal Phlegmatic stool is smooth and moist.
Soft, sluggish Phlegmatic stools are often associated with a slow, deficient pepsis and a hypoactivity of the Metabolic Heat and digestive fire. If the stools should also be loose with pieces of undigested food in them, this indicates a bona fide case of dyspepsia.
Another common Phlegmatic type of stool is the mucoid stool; the stool will have visible streaks, or veins, of mucus running through it. Clumps or deposits of semisolid phlegm, or mucus, can accumulate in the intestines and digestive tract just like they can in the nose, throat and respiratory tract.
Phlegmatic loose stools or diarrhea will often occur in the early morning upon arising. This is the time of day when the Metabolic Heat is at its lowest.
Choleric (Hot and Dry): Yellow bile, with its hot, sharp quality, has a laxative effect and provokes the defecation reflex. Since yellow bile is the dominant humor in those of a Choleric temperament, stools will tend to be soft, greasy or unctuous, and may often have a strong or foul odor. Intestinal transit time tends to be short, since the Metabolic Heat is very active in Cholerics.
If there is an infection of the bowels, which is another Choleric condition of excess heat, the bowels will be agitated, and the diarrhea more urgent and severe. The more virulent the infection, the more vehement and severe will be the diarrhea. In dysentery, not only will there be vehement diarrhea, but blood may also be present in the stools. Ulcerative colitis will produce diarrhea mixed with blood and mucus.
If bile is congested in the liver and gall bladder and isn't flowing smoothly, there will often be constipation. The stools will be hard, dry and compact from the excess heat, and light in color, due to the deficiency of bile. In these cases, strong cholagogues, as well as laxatives, are needed to stimulate the flow of bile and remove blockages and obstructions to its flow.
Sometimes, both phlegm and bile are excessive, or aggravated. In these cases, the stools will be large and copious, soft, slimy, smelly, and bright yellow. The stool will often burn the anus as it's being passed. There may also be a sallow, jaundiced complexion, a sluggish digestion or indigestion, and generalized lethargy or malaise.
Abnormal forms of yellow bile will color the stools green. This usually indicates that the Innate Heat of pepsis, or digestion and metabolism, is low.
Melancholic (Cold and Dry): Because of the Retentive virtue of black bile, the dominant humor in those of a Melancholic temperament, constipation is common. When the stools come out, they are usually small, hard, compact and dry, and may have a silvery gray sheen to them, which indicates the presence of black bile.
Melancholics also suffer from colicky digestive complaints, with lots of gas, distension and bloating. If a lot of gas is present in the stool, it will float in the toilet bowl. An even larger amount of gas, or flatulence, will honeycomb the stools, making them rough, irregular in shape, and porous. Such stools are also called costive, and are a common stool type seen in Melancholic individuals, as well as those with excess wind and black bile in the bowels.
Irritable bowel is another common syndrome seen in Melancholic individuals, and is characterized by alternating constipation and diarrhea. Morbid charred or oxidized forms of black and yellow bile, which are irritating to the GI mucosa, are often associated with this condition.
If large amounts of black bile are passed in the stool, the stools will be blackish in color. This is generally not a good sign.
Basic Diagnostic Parameters of the Stool
There are certain basic parameters of the stool that the physician considers in making his assessment of the patient's condition. These are the stool's volume, color, consistency and odor.
Stool Volume should be commensurate with the amount of food and drink consumed. A copious stool is one whose volume is excessive in relation to the quantity of food and drink consumed. A scanty stool is one whose volume is significantly less relative to the amount of food and drink consumed.
When the stool is copious, there are basically two things that could be going on. The first possibility is that the digestive system and Natural Faculty aren't efficiently extracting all the nutritive essences from the food and drink consumed. This is generally called an assimilation disorder, and is usually associated with a weak pepsis and digestive fire. Certain food allergies or sensitivities to things like gluten can also create stools like this.
The second possibility is that the organism is using the stool to discharge excessive or superfluous humors that have accumulated. This is often something that is out of the ordinary, and the patient may make a remark about it. Under the right conditions, wastes that have been held within the body and in the bowels may be discharged, or released.
If there is an inadequate digestion and absorption of nutrients, the patient will be tired and run-down, especially after passing the stool. If excessive or superfluous humors are being discharged, defecation should bring relief and an enhanced sense of wellbeing.
If the stool is scanty, the usual problem is that the stools aren't being completely evacuated, and excess fecal matter is being retained in the cecum and colon. Chronically retained fecal matter may become impacted, and retained wastes may back up all the way into the small intestine, causing colic, gas and reflux symptoms in the middle and upper digestive tract.
Greek Medicine stresses the importance of proper intestinal waste management, and keeping the bowels clean and functioning properly. Constipation is called the Mother of All Diseases. The bowels of the human body can be compared to the roots of a tree; if the colon is congested and toxic, it's like the roots of the body are being poisoned, which will poison the whole organism.
If the stools are copious, they are also usually soft; such is the nature of the moist, flourishing humors of the organism. If the stools are scanty, they are usually, but not always, hard, dry and compacted. Wetness feeds and flourishes, dryness withers and shrinks.
If the stools are soft and loose but also scanty, there are also usually colicky symptoms involved. Such is often the case in irritable bowel, intestinal infections and parasites. In dysentery, there can be marked tenesmus, or a desire and urge to evacuate the bowels which is unproductive, in addition to frequent loose stools and diarrhea.
Stool Color should be, normally, a rich, deep brown. This indicates that the bile is flowing smoothly. If the bile is not flowing smoothly, the stools will be a light brown, yellowish or pale colored. If there is excessive phlegm and dampness as well as an aggravation of bile, the stools will be a bright yellow. Greenish stools indicate a deficient Innate Heat of pepsis and digestion. Stools with a reddish tint indicate the possible presence of blood. Black bile will color the stools a steely gray, or make them blackish in color. Back, tarry stools can indicate bleeding higher up in the GI tract. Reddish stools are often passed at the crisis point of a disease.
Stool Consistency should be semisolid - firm, but not hard, and well-formed. Basically, soft or loose stools are Wet in temperament, whereas hard, compact stools are Dry.
Soft or loose stools, if they are not foul smelling, generally indicate a deficient pepsis and metabolic heat that don't concoct or ripen the stool and reabsorb excess fluids adequately. If the stools are soft and slimy, this usually indicates excess phlegm.
Soft or loose stools that do have a foul odor are usually due to aggravated bile and excess heat and choler. Signs and symptoms of urgency or irritable bowel may also be present.
Porous, costive or irregularly shaped stools are usually due to the presence of excess wind - flatulence, or gas. such stools will usually float in the toilet bowl.
Stool Odor in the normal stool should not be totally absent; a healthy stool should have a characteristic musky odor. Odors in excess of this, or strange and unusual odors, are definitely abnormal. Most cases of a foul-smelling stool are due either to fermentation or putrefaction in the intestines, or to aggravated yellow bile. A rotten odor of the stool is often indicative of an imbalance of intestinal flora.
The Traditional Healer's Handbook by Hakim G. M. Chishti, pp. 106 - 107
@ 1988, 1991 by Hakim G. M. Chishti, Pub. by Healing Arts Press - Rochester, VT, USA
Al-Qanun Fi'l-Tibb Book I by Avicenna pp. 245 - 247
@1993 by Jamia Hamdard, New Delhi, India