Frequency

A normal bowel movement is once or twice a day. Any evacuation that occurs with less frequency than this constitutes constipation. A bowel movement (which may or may not be loose) occurring more than three times a day is considered to be too frequent.

Constipation is the most common disturbance of frequency of evacuation but its clinical significance cannot be separated from the consistency of the stools. Constipation indicates not only the infrequent passage of stools, but also excessive dryness of the stools or difficulty and straining in passing stools.

Acute constipation with thirst and yellow tongue coating indicates acute Heat in the Stomach and Intestines.

Chronic constipation in old people or women may be due to Blood or Kidney deficiency; in this case the stools would be slightly dry and there would be other signs of Blood or Kidney deficiency.

If the stools are bitty, small and difficult to pass, this indicates Liver-Qi stagnation or Heat in the Intestines (if they are also dry); when it is due to Liver-Qi stagnation, it often alternates with diarrhoea or loose stools as so often happens in irritable bowel syndrome.

Constipation with dry stools indicates Heat in the Large Intestine or Yin deficiency and Dryness of the Stomach, Intestines or Kidneys. If there is difficulty in evacuation but the stools are not dry, this indicates Liver-Qi stagnation.

Constipation with abdominal pain that is relieved by the bowel movement indicates retention of food or Dampness in the Intestines; constipation with abdominal pain and distension that is not relieved by the bowel movement indicates Liver-Qi stagnation. Constipation with abdominal pain and a pronounced feeling of cold indicates Cold in the Intestines.

Spleen-Qi deficiency normally causes loose stools but in a few cases a severe Spleen-Qi deficiency may cause constipation because the deficient Spleen-Qi fails to move and transport. Constipation may also be caused by a so-called “shut-down” of the Qi mechanism; this happens when there is an impairment of the ascending and descending of Qi in the digestive system, which may be seen, for example, after surgery.

Alternation of constipation and loose stools indicates stagnant Liver-Qi invading the Spleen.

If the stools are not loose but very frequent and the person cannot hold them easily, this indicates deficiency of the Central Qi, that is, the Qi of Stomach and Spleen; it also indicates sinking of Spleen-Qi.

Box 31.1 summarizes patterns underlying constipation and increased frequency.

Consistency

The normal stool is well formed, not loose, not too dry and floating.

An excessively dry stool indicates either Heat in the Intestines, Blood deficiency (of the Liver) or Yin deficiency (which may affect the Large Intestine, Spleen, Liver or Kidneys).

Loose stools generally indicate a deficiency of the Spleen or Kidneys, or both. A deficiency of the Spleen is by far the most common cause of chronic diarrhoea or loose stools; a Kidney deficiency is a common cause of chronic diarrhoea in the elderly. If the diarrhoea is severe and very watery, this usually indicates Yang deficiency (of the Spleen and/or Kidneys, or both), whereas loose stools usually indicate Spleen-Qi deficiency.

The most common cause of chronic diarrhoea is Spleen-Qi or Spleen-Yang deficiency. Chronic, watery diarrhoea occurring every day in the very early morning is due to Kidney-Yang deficiency and is called “cock-crow diarrhoea” or “fifth-hour diarrhoea” (this refers to the ancient Chinese way of measuring time in each 24 hours).

There are, however, also Full causes of diarrhoea and principally Dampness (which could be associated with Heat or Cold) and Cold in the Spleen and Intestines.

The presence of a foul smell with the diarrhoea or loose stools suggests Heat in the Intestines, whereas the absence of smell is either normal or suggestive of Cold.

The presence of pain with the diarrhoea or loose stools suggests Liver-Qi stagnation, Cold or Damp-Heat.

The presence of mucus in the stools indicates Dampness while the presence of blood indicates deficient Spleen-Qi not holding Blood, Damp-Heat or Blood stasis in the Intestines. Acute diarrhoea or loose stools are usually due to invasion of external Dampness, which may be seen in food poisoning; with a foul smell it is due to Damp-Heat, without smell to Damp-Cold.

Undigested food in the stools, stools following blood or diarrhoea with borborygmi indicates Spleen-Qi deficiency; a burning sensation of the anus indicates Damp-Heat in the Intestines.

Sticky stools that necessitate brushing the toilet with a toilet brush every time indicate Dampness in the Intestines.

Case history 31.1 illustrates a pattern underlying diarrhoea.

Box 31.2 summarizes patterns underlying loose stools and diarrhoea.

Shape

Stools like small pellets indicate Liver-Qi stagnation, or Heat if they are also dry. Long and thin stools like pencils indicate Spleen-Qi deficiency (bear in mind that they could also indicate carcinoma of the bowel) (Fig. 31.1).

Colour

Normal stools are light-brown in colour. Pale-yellow stools indicate Empty-Heat (of the Spleen, Large Intestine or Kidneys). Dark-yellow stools indicate Full-Heat (of the Large Intestine). Dark stools may indicate the presence of occult blood and they generally indicate Heat (of the Large Intestine). Pale, almost white stools indicate Cold in the Large Intestine. Green stools indicate Liver-Qi invading the Spleen. Red stools indicate the presence of fresh blood and this may be due either to Heat in the Large Intestine or to Spleen-Qi deficiency. Greenish-bluish stools indicate the penetration of external Cold into the Large Intestine (common in babies).

Black or very dark stools indicate Blood stasis. Bright-red blood coming before the stools and splashing in all directions indicates Damp-Heat in the Intestines. If the blood comes before the stools and is turbid and the anus feels heavy and painful, this indicates Blood-Heat. If the stools come before the blood and this is watery, it indicates that Spleen-Qi is deficient and is unable to hold Blood.

Box 31.3 summarizes the patterns underlying stool colours.

Odour and sounds

Hearing and Smelling, Chapters 53 and 54

Generally speaking, an absence of smell is either normal or it indicates Cold in the Intestines. A strong, foul smell usually indicates Heat and especially Damp-Heat. A sour smell indicates a disharmony of Liver and Spleen.

Flatulence may be due to Liver-Qi stagnation, to Damp-Heat if there is a foul smell, or to Spleen-Qi deficiency if there is no smell.

Borborygmi with loose stools indicate Spleen deficiency; borborygmi with abdominal distension and without loose stools indicate stagnation of Liver-Qi.

Box 31.4 summarizes patterns underlying odour and sounds.

Abdominal pain related to evacuation

The feeling of distension before evacuation indicates Liver-Qi stagnation. Abdominal pain before evacuation but not relieved by it also indicates Liver-Qi stagnation. Abdominal pain during evacuation (and generally relieved by it) indicates Dampness in the Large Intestine or retention of food. Abdominal pain during evacuation, which is not relieved by it, generally indicates Cold in the Large Intestine. Abdominal pain after evacuation is normally due to Spleen-Qi deficiency.

Case history 31.2 illustrates a pattern underlying constipation with pain.

Box 31.5 summarizes patterns underlying abdominal pain.

Frequency

As a general principle, enuresis or incontinence of urine is usually due to Deficiency conditions whereas retention of urine is generally due to a Full condition, but there are exceptions to this rule. For example, severe Qi deficiency of the Lungs and Spleen in the elderly may lead to urine retention.

Frequent urination is generally due to Kidney-Yang deficiency, in which case the urine is pale and abundant; if it is frequent but scanty it indicates Spleen- and Kidney-Qi deficiency.

Nocturnal enuresis in children is due either to a constitutional Kidney deficiency or to Liver-Fire; in the first instance the child will be quiet and listless, while in the case of Liver-Fire the child will be vivacious and prone to fits of anger.

Colour

The colour of the urine gives a good indication of the Hot and Cold condition of the patient. Normal urine is pale yellow. Pale urine indicates Cold in the Bladder or Kidney-Yang deficiency; dark urine indicates Heat in the Bladder or Kidney-Yin deficiency. It should be remembered that the colour of the urine is affected when the person drinks a lot of water (becoming paler than it would otherwise be) and also when the person takes vitamin B, which makes the urine bright yellow.

Blood in the urine indicates either Qi deficiency (of the Spleen and Kidneys), Heat in the Bladder or Kidney-Yin deficiency.

Very dark urine, like soya sauce, indicates a kidney disease such as kidney failure or glomerulonephritis.

Box 31.6 summarizes patterns underlying urine colours.

Amount

Copious urination indicates Kidney-Yang deficiency; scanty urination indicates Kidney-Yin deficiency or Heat in the Bladder unless it is due to profuse sweating, repeated vomiting or severe diarrhoea. If the urination is scanty but also frequent, it is normally due to Spleen- and Kidney-Qi deficiency. Copious, clear and pale urination during an exterior invasion of Wind indicates that the pathogenic factor has not penetrated into the Interior (if it had, the urine would be dark).

Difficulty in micturition

Retention of urine from Full patterns may be due to Dampness obstructing the urinary passages, to Blood stasis in the Bladder or to urinary stones. Retention of urine from Empty patterns may be due to Kidney-Yang deficiency, Kidney-Yin deficiency or a deficiency of the Lungs; all these patterns occur mostly in the elderly.

Difficulty in urination (meaning that the micturition is difficult or that it may stop and start) is usually due to Dampness obstructing the urinary passages; a slight difficulty in urination may also be due to Spleen- and Kidney-Qi deficiency. In the elderly, it may be due to Kidney-Yang deficiency; in rare cases, it may be due to Lung-Qi deficiency.

Cloudiness

Turbid urine indicates Dampness in the urinary passages. Urine with small flakes of mucus indicates Damp-Heat in the Bladder.

Incontinence

Incontinence of urine is always due to a deficiency of the Kidneys and sinking of Kidney-Qi; it is common in the elderly and in women after childbirth or after a hysterectomy.

Dribbling of urine after urination indicates the Kidney-Qi is not firm.

Urination at night

Urinating at night indicates Kidney-Yang deficiency. This is due to deficient Yang not controlling Yin at night and therefore fluids leaking out in urination.

Pain

Pain and hypogastric distension before urination indicate Liver-Qi stagnation; burning pain during urination indicates Damp-Heat in the Bladder; a dull ache after urination indicates Kidney-Qi deficiency.

Smell

Absence of smell is either normal or indicates Cold in the Bladder; a strong smell indicates Damp-Heat in the Bladder. A sweet smell of the urine may indicate diabetes.