Indian Journal of Traditional Knowledge Vol. 13(3), July 2014, pp. 466-472

Medicinal herbs: Traditional knowledge used for constipation therapy in metropolitan

Prayosh Suntonvipart1*, Songkoon Chantachon1 & Marisa Koseyayothin2 1The Faculty of Cultural Science, , Khamriang Sub-District, Kantarawichai District, Province 44150, ; 2Kanchanapisek Non-Formal Education Centre (Royal Academy), Salaya Sub-District, Bhuttamonthon District, 73170, Thailand E-mail: [email protected]

Received 12.03.14, revised 28.03.14

This qualitative research examines constipation therapy with herbal remedies in metropolitan Bangkok. Observation, personal communication and focus group discussion techniques are used to assess traditional medicinal knowledge used in the treatment of constipation and the innovation of Thai herbal remedies. The results show that herbal remedies chosen by doctors have limitations caused by complicated formulation processes and inconvenience for use by patient in modern society. The researcher team developed a new herbal remedy named Phothiphawadi, which was then formulated into capsule dosage form and dispensed to patients with constipation. Patients were able to carry and use Phothiphawadi capsules more easily. After taking this product together with lifestyle changes, all patients recovered from constipation. The Phothiphawadi capsule was an effective treatment with few side effects and a low price.

Keywords: Thai traditional medicine, Traditional knowledge, Constipation, Medicinal herbs, Herbal remedies

IPC Int. Cl.8: A61K 36/00, A01D 7/48

The study of healthcare is both a science and an art. traditional Thai medicine by supporting use of Local Thai knowledge has been combined with medicinal herbs in the health system. knowledge from neighbouring civilizations. This In the face of global economic and social changes mixture has developed and been inherited as a and an increasing desire to cure diseases naturally, the medical system today, which is both recorded as Thai government supports and develops Thai evidence and relayed as beliefs in various ethnic traditional medicine to make sure that various groups. The medical system is currently known as conditions can be treated by traditional Thai 1 Thai traditional medicine or Thai folk medicine . The medicine. One such affliction is constipation, which tenth Thai national economic and social development occurs in country and city dwellers alike. plan (2007-2011) aimed to improve the quality of all Constipation is caused by a number of daily activities. Thai people by developing their physical, mental and Given the hectic lifestyle of the modern family, many occupational skills, knowledge and ability. The aim of workers suffer from constipation due to disruption of the policy was to start by strengthening the health of their regular diet or routine and stress and anxiety Thai people with appropriate environmental and from everyday problems. Constipation is usually easy dietary changes. These were integrated into the Thai to prevent with simply behaviour modifications and health system, which discouraged behaviour environmental adjustments3. Nowadays, people in associated with health risks. Thai traditional and modern society, both in Thailand and abroad, place alternative medical research and development was similar emphasis on alternative chemical-free also improved to enhance quality of life and economic medicine for their healthcare. Constipation 2 value . In addition, the eleventh national economic medication in modern society is mostly laxative- and social development plan (2012-2016) also based, which could cause side-effects and regulated health, targeting the development of intoxication. Although herbal remedies for —————— constipation treatment are effective, they have *Corresponding author unstable active substances and are difficult to use and SUNTONVIPART et al.: HERBS USED FOR CONSTIPATION THERAPY IN BANGKOK 467

carry. The challenge is to integrate medical people. After all data had been collected, it was knowledge and develop new treatments appropriate validated using triangulation and research data was for modern society, while continuing to focus on presented as a descriptive analysis4. The study was principles of cultural heritage in healthcare. The conducted from September 1, 2012 to May 31, 2013. research team were thus interested in studying traditional knowledge used in metropolitan Bangkok Results to review existing treatments and develop an effective Constipation is usually caused by a disorder of new Thai herbal remedy for patients with bowel function due to human behaviour such as a constipation. hectic lifestyle, unhygienic diet, stress or lack of exercise. In some cases, constipation can be caused by Methodology structural problems. Yupin Sae-Ung (personal This research has three primary objectives: to study communication, 2013), a patient from Khoom-Nukul existing constipation therapy with herbal Thai traditional medicine clinic said she has to leave remedies, to develop a convenient and portable her home at Phra Samut district, Samut Prakan herbal remedy for constipation therapy and to province at 6.30 a.m. every morning and take two study the effect of constipation treatment using the buses to her office in Yanava district, Bangkok. She developed herbal remedy. For this qualitative must arrive before 8.30 a.m. so has to control her research, the researchers used four criteria to identify bodily functions so that they do not delay her journey. the research area: there was a traditional Thai This has made her constipated for 2 yrs. Maneerat medicine clinic; there were traditional Thai medicinal Chanmee (personal communication, 2013), a patient practitioners; patients with constipation in the area from Sukhothai Thammathirat traditional Thai preferred traditional medicinal treatments; there was a medicine clinic, Pak Kred district, Nonthaburi network for treatment information and consultation. province explained that she has to work at the office The research area was composed of: from 8.30 to 16.30 and gets paid for three hours of 1. Khoom-Nukul traditional Thai medicine clinic, overtime work. She has many responsibilities to finish Phra Samut Chedi district, . and feels stressed and worried that she cannot 2. Chetuphon traditional Thai medicine clinic, Phra complete her jobs in time. This has made her Nakhon district, Bangkok. constipated for over two years. Two doctors, Dr. 3. Sukhothai Thammathirat traditional Thai Pongporn Surathip (personal communication, 2013) medicine clinic, Pak Kred district, Nonthaburi and Dr. Wanpapat Dinteb (personal communication, province. 2013), were asked for their assessment of constipation The research sample was selected using a from a traditional perspective. According to purposive sampling technique. 121 randomized traditional Thai medicinal principles of disease samples were identified and divided into three groups. development, the doctors explained that constipation The first group of 30 key informants was composed of is caused by a disorder of the element of wind, called traditional Thai doctors who were experts in the Vayo Dhatu. This wind, which normally moves symptoms of constipation and had at least 10 yrs upward (causing blushing, coughing and sneezing) or experience. The second group of 30 casual informants downward (causing bowel movements and was composed of traditional Thai doctors who treated flatulence), gets stuck in the upper abdomen. This patients with constipation. The final group of 61 causes symptoms of dyspepsia, abdominal disorder general informants was composed of patients with and later becomes constipation. There are three constipation, relatives and people in the community. traditional herbal remedies to treat the condition: 1) Data was collected by in-depth personal Thorani-Santhakat; 2) Uddhangamavata formula communication. The research team created personal number one; 3) Ya-Tai. The use of these herbal communication questions based on the study aims and remedies among key informants were analysed research framework which prevented the interviewer during focus group discussions and it was found that from offering personal suggestions or emotional all three had been used to relieve symptoms of opinions. The guidelines for the interviews are constipation and gastro-intestinal diseases. They detailed in the appendix to this paper (Appendix). are part of an ancient healthcare culture in Thailand The research team also used participation observation based on two ancient scriptures, Dhatu Bunjob and and six focus group discussions, involving 6-10 Uthorn-Rok. 468 INDIAN J TRADITIONAL KNOWLEDGE, VOL 13, NO. 3, JULY 2014

Table 1—Phothiphawadi herbal remedy ingredients No. Common name Scientific name Selected Properties 1 Rhubarb, Chinese rhubarb Rheum palmatum L. Anti-inflammatory, antibacterial, laxative 2 Blonde syllium seed, Indian plantago seed Plantago ovata Forssk. Dietary fibre not absorbed by small intestine 3 Emblic mirobalan, Indian gooseberry Phyllanthus emblica L. Digestive 4 Beleric myrobalan Terminalia bellirica (Gaertn.) Roxb. Reduces cholesterol, digestive 5 Indian senna Senna alexandrina Mill. Laxative 6 Mock willow, Black chuglam, Citrine Terminalia citrina (Gaertn.) Roxb. ex Digestive myrobalan Fleming 7 Yellow myrobalan, Chebulic myrobalan Terminalia chebula Retz. Laxative (unripe) 8 White marudah Terminalia arjuna (Roxb. ex DC.) Analgesic, anti-inflammatory Wight & Arn. 9 Cinnamon tree, Ceylon cinnamon Cinnamomum verum J. Presl Anti-flatulent

During focus group discussions, key informants capsule. The Phothiphawadi capsule trial was from three traditional Thai medicine clinics agreed to successful. formulate a new herbal remedy named Phothiphawadi. There were nine herbal ingredients Discussion for the remedy, described in table 1 (Table 1). The Illness makes people lose both physical properties ingredients were crushed in equal parts and combined and social functions, thus patients try to recover as in 250mg capsules. Dr. Arun Techametheekul fast as they can. Commonly, household constipation (personal communication, 2013) suggested that therapy consists of a single medicinal vegetable capsule medicine (Fig. 1) is currently popular because around the home, such as tamarind, lemon basil seeds of more convenient portability and longer stability. soaked in water or ripe papaya. However, there are The research team manufactured this herbal remedy in some limitations, such as temporary effect and mild seven stages (Fig. 2): herb preparation, drying, treatment. The patients eventually have to ask chopping, powdering, sieving, capsule-filling traditional Thai doctors to formulate and dispense (250 mg) and packaging in plastic bottles or blisters herbal remedies that are more effective than a single (Figs. 3-4). For a successful course of treatment, two herb. It is the responsibility of traditional Thai doctors Phothiphawadi capsules must be taken at bedtime for to provide the best treatment and the duty of the five days. patient to follow their prescription. This relationship The capsule was tested on 45 patients with between the traditional doctor and their patient is a constipation from 20 - 60 yrs old (Table 2). All representation of the structural functional theory. 45 patients experienced symptoms of constipation for People in society have to cooperate within community at least one year. These symptoms included: fewer or family structures, with lifestyles reliant on social than 3 instances of defecation per week; hard stools or norms and regulations. If any act or behaviour is stools made up of small, hard pellets; more frequent different from that norm, the culprit may be punished 5 and longer instances of straining during defecation; a or ignored by society . feeling of incomplete evacuation of faecal matter. Herbal remedies for constipation therapy in the three After the patients had taken two Phothiphawadi traditional medicine clinics commonly consist of active capsules for five days and had made life changes for ingredients with strong laxative effects that have to be one month, results show that the number of desiccated or reduced prior to formulation. This means defecations per week increased, stools became longer, a higher risk of drug side effects, a more complicated smoother and softer, defecation became easier and a process, higher cost and longer time of drug larger quantity of faecal matter was evacuated, preparation. These remedies are usually boiled as a making the patient feel complete in their evacuation drink for 5-10 minutes, which is inconvenient for (Table 3). In addition, the research team found that patients in a rush-hour society. The Phothiphawadi there were no side effects in any of the 45 patients, capsule solves this problem because all active both during and after taking the Phothiphawadi ingredients are easy to prepare and formulate, there SUNTONVIPART et al.: HERBS USED FOR CONSTIPATION THERAPY IN BANGKOK 469

Fig. 1-4: fig. 1—Capsule dosage form, Fig. 2—Capsule formulating process, Fig. 3—Plastic bottle containing developed capsules & Fig. 4—Capsules in blister are less ingredients and each ingredient is easily Table 2—Details of constipated patients studied replaced by others with similar properties. Information Detail Phothiphawadi capsules are portable, with plastic bottle and blister containers, and are easily taken Gender without an adverse taste or smell. In a study of Male 23 Chromolaena odorata (L.) R. M. King & H. Rob. Female 22 Haemostatic topical gel development, Nattaya Age Silawan and her team found that this topical gel Range 20-60 yrs satisfied patients and staff due to the potency of the Mean 40 yrs haemostatic effect, ease of formulation and use, lower Medication inducing constipation experience 6 cost and reduced side effects . Anti-hypertensive drug n/a To sustain recovery from illness by traditional Thai Drug contain Calcium n/a therapy, patients need to modify their lifestyles. Drug contain Ferrous n/a According to a study monitoring gastro-intestinal Drug contain Aluminum n/a disease treatment of traditional clinics in public health centres, Nittaya Namwiset found that patients were cured by a combination of herbal remedies and Thai medicine. Saesawang found that life strict lifestyle changes7. This also corresponds to modification is an important factor in curing patients Chokechai Saesawang, who studied the effect of with haemorrhoids who take Ridsiduang Mahakan Ridsiduang Mahakan herbal remedies in traditional herbal remedies8. 470 INDIAN J TRADITIONAL KNOWLEDGE, VOL 13, NO. 3, JULY 2014

Table 3—Comparison of defecation behavior among patients recommend the results of this cultural research to with constipation other healthcare personnel to expand treatment and Information Pre-intervention Postintervention disseminate the results in other publication media. Number of defecations per This would advertise the potential of traditional Thai week medicinal knowledge and convince more people to Less than 3 times 45 - turn back to traditional Thai medicinal services. More than 3 times - 45 Stool Conclusion Hard pellets 35 - Phothiphawadi was developed as a herbal remedy Hard and short 10 - to treat constipation by using traditional Thai Hard sausage-like - - medicinal knowledge. The new dosage form is easier Sausage-like - - and more convenient to carry that existing treatments Soft sausage-like - 35 and is recommended for patients with constipation. Soft blobs with clear-cut - 10 Phothiphawadi is another alternative for people edges interested in turning to traditional Thai medicine. Fluffy pieces with ragged - - edges Watery, no solid piece - - References Straining defecation 1 Soralum P & Temsirirerkkul R, Medicinal herb encyclopaedia, Vol.1, Siri Rugkhachati Nature Park [in More straining time 45 - Thai], (Department of Pharmaceutical Botany, Faculty of Normal straining time - 45 Pharmacy, Mahidol University, Bangkok), 2010. Sense of defecation 2 Office of the National Economic and Social Development Feeling of anorectal 10 - Board, The national economic and social development plan, th obstruction 10 edn, (2007-2011) [in Thai], (Office of the Prime Incomplete evacuation 35 - Minister, Bangkok), 2006. 3 Kraiphiboon P, Gastro-intestinal diseases [in Thai] (Amarin Normal evacuation - 45 Health, Bangkok), 2011. Require manual manoeuvres 4 Chantavanich S, Data analysis in qualitative research to facilitate defecation [in Thai] (Chulalongkorn University Press, Bangkok), 2010. Yes 5 - 5 Sanyawiwat S, Social development theories and strategies No 40 45 [in Thai], (Chulalongkorn University Press, Bangkok), 2007. Further research must be focused on the integration 6 Silawan N et al., Chromolaena odorata (L.) King et Robins. haemostatic topical gel development [in Thai], Thai between Thai traditional medicine and modern Traditional Medicine and Alternative Medicine Journal, 6(2) medical knowledge in other disease therapies with (2008) 120. traditional herbal remedies. There must be further 7 Namwiset N, Gastro-intestinal diseases treatment monitoring clinical trials about the effectiveness of herbal in Thai traditional medicine clinic in public health centre [in remedies and other medicinal herbs. While the herbal Thai], Thai Traditional Medicine and Alternative Medicine Journal, 7(2) (2009) 69. remedy created as a conclusion to this research can 8 Saesawang C, Effective of Ridsiduang Mahakan herbal treat symptoms of constipation effectively at a low remedies monitoring [in Thai], Thai Traditional Medicine cost, it is necessary for the ministry of public health to and Alternative Medicine Journal, 7(2) (2009) 66.

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Appendix Personal communication question guidelines Group of respondents Topics • Purpose of Thai traditional medicine business management • Concept of Thai traditional medicine transaction management • The way to motivate people to turn back to traditional medicinal services • Network establishing and synchronizing traditional Thai medicine • Guideline of traditional Thai medicine clinic management in line with the Act of Practitioners Entrepreneurs in traditional • Government cooperation in natural resource conservation medicine clinics • Visions of traditional medicine development to be accepted from Thai and international societies • Opinion about green industry • Problems, threats and suggestions • Opinion about Phothiphawadi herbal remedy • The way to motivate people to turn back to traditional medicinal services • Network establishing and synchronizing traditional medicine • Guidelines of traditional medicine clinic management in line with the Act of Practitioners Practitioners in traditional • Achievement factors in traditional medicine operation medicine clinics • Opinions about traditional medicine in constipation therapy • Opinions about herbal remedies and formulations • Opinions about the innovation of Thai herbal remedies with easier use • Opinions about world safe and portable packaging • Problems, threats and suggestions • Teacher mantle and responsibility to provide knowledge of traditional Thai medicine • Concept to perform as a teacher and traditional practitioner • Opinions about the traditional Thai medicinal theory of the human body and causes of diseases • Knowledge and opinions about constipation therapy o Number of herbal remedies used by patients with constipation Traditional medicine teachers o Active ingredients and their properties • Opinions about using herbal remedies instead of modern medicine • Opinions about Thai herbal remedies and formulations • Opinions about the innovation of Thai herbal remedies with easier use • Opinions about world safe and portable packaging • Problems, threats and suggestions • Personal information o General information o Occupation and revenue o Family history • Details on the residential community o Community background o Lifestyle o Belief, tradition, ceremonies, prohibition • Community geography o Geographical location Traditional medicine doctors in o clinic Transportation o Population • Traditional Thai medicine and its use o Concept of knowledge development o Treatment practice experience o Opinions about the innovation of portable Thai herbal remedies with easier use o Treatment result in general diseases, also constipation o Processes of diagnosis, drug preparation, dispensing, monitoring and counseling o Constipation therapy experience o Refunds o Problems, threats and suggestions Patients and customers • Personal information 472 INDIAN J TRADITIONAL KNOWLEDGE, VOL 13, NO. 3, JULY 2014

• Opinions about Thai traditional medicine and alternative medicine service for health care • Information of defecation behavior o How suffering o Impact on occupation o Impact on life o Medication history, where/when/how o What brings you to get Thai traditional medicine treatment/How do you know • Opinions about traditional Thai medicine in constipation therapy • Patient procedures to get traditional Thai medicine services • Thai traditional medicinal service accession compared with modern medical service • Advantage and disadvantage of Thai traditional medicinal service compared with modern medical service o Environment o Convenience before and during treatment o Waiting time o Service mind o Duration of treatment o Payment o Treatment result o Monitoring after treatment • Opinions about the innovation of portable Thai herbal remedies with easier use for constipation therapy • Problems, threats and suggestions •