Smith: Constipation in Children. 
CONSTIPATION IN CHILDREN! 
J. LEWIS SMITH, M.D., 
BY 
Clinical Professor of Diseases of Children in Bellevue Hospital Mgflifeai CbWege. 
The gastro-intestinal portion of the digestive apparatus 
a double function. Eirst, it receives and retains the food dur- 
ing the process of digestion; it furnishes the most important 
of the liquids by which digestion is effected, and it absorbs 
those products of digestion which are required for the nutrition 
of the body, while it serves as a barrier against the admission 
of refuse matter. Secondly, it has an excretory function, so 
that a large part of the waste and noxious products of the sys- 
tem are eliminated from its surface. Having, therefore, a 
relation so close and fundamental to the general nutrition, it 
is necessary, for the normal activity of the organs and the 
maintenance of health, that its functions should be regularly 
and fully performed. But retention of fecal matter beyond 
the normal period is one of the most common ailments both 
in infancy and childhood, and occasionally it constitutes a 
grave disease. 
Constipation is of two kinds, namely, symptomatic and idio- 
pathic. 
Symptomatic Constipation. Causes.—Many of these are 
obstructive. The more common of them are the following: 
(a) Congenital stenosis, or occlusion of the anus or rectum. 
The anus is not formed, or it terminates in a cul-de-sac, while 
the lower end of the large intestine forms another cul-de-sac. 
These two cul-de-sacs, lying opposite each other, one looking 
upward and the other downward, may be separated from each 
other by a small interspace, a fibrous septum, so that relief can 
be obtained by a puncture or incision, or they may be widely 
separated, so that there is no possible mode of relief, and death 
is inevitable, unless the fecal matter escapes through a con- 
genital fistulous passage upon one of the adjacent mucous sur- 
faces, which mode of relief was present in forty per cent of 
the cases of this obstruction collected by Leichtenstern. Excep- 66 
Smith: Constipation in Children. 
tionally this malformation occurs in the sigmoid flexure, while 
the rectum is normal. The stenosis, if slight, may produce little 
delay in the evacuations, except when hardened masses or 
coarse, indigestible substances descend upon it, and it may, 
therefore, with careful selection of diet, cause little inconveni- 
ence for a lengthened period, while much stenosis causes early 
obstructive symptoms. 
Barely the stenosis is at the ileo-cecal orifice. Thus, in the 
Transactions of the Bond. Bath. Soc. for 1870, is the history 
of a case in which there was such narrowing of the ileo cecal 
orifice, believed to be congenital, that a No. 9 catheter could 
barely be passed through it. The patient lived till his thirty- 
second year, having suffered from an early age with frequent 
attacks of colic and constipation. After his death, the ileum 
next to the ileo-cecal valve was found to have a diameter of 
seven inches, while the large intestine was much atrophied, 
and its entire lumen contracted from the long disuse. Occa- 
sionally, the narrowing occurs a little above the ileo-cecal 
orifice, and more rarely in the duodenum, at the point of union 
of the pancreatic or bile-duct with the intestine. In the last 
situation, the obstacle sometimes appears to be hypertrophied 
valvulse conniventes, the edges of two opposite folds becom- 
ing more or less adherent. Such congenital intestinal obstruc- 
tions, whether, as is probable, produced by inflammations in the 
fetus or from simple perverted nutritiou; whether arising 
from syphilitic cachexia or other cause, of course, retard the 
evacuations, according to their locations and the degree of 
closure. The same degree of stenosis in the colon or rectum 
obviously causes more constipating effect than in the small in- 
testine, since the excrementitious substance is firmer in the 
former than in the latter, and the latter have more mobility 
by which to overcome obstacles. 
(b) Intestinal Displacements.—These produce obstructions of 
a very painful and dangerous kind. Intussusception and exter- 
nal hernia are too well known to require description. Both 
are apt to produce complete obstruction if not soon relieved, 
but there are cases of intussusception in children in which the 
displaced intestine remains pervious, and the evacuations 
occur with more or less regularity ; and the same is true of Smith: Constipation in Children. 
67 
one form of hernia, namely, the congenital, which, although 
painful, seldom produces serious obstruction. 
Painful and dangerous occlusion and consequent arrest of 
alvine evacuations occasionally results from the imprisonment 
of a loop of intestine in an opening, usually congenital, in the 
mesentery or diaphragm, or from the knotting of one portion 
of intestine with another, as described by Leichten stern, or again 
from the twisting of the intestine. Thus, in the Centralb. f. 
d. med. Wissensch. for April 24th, 1879, Epstein and Soyka 
relate the case of a new-born infant that died in the second 
week after birth with symptoms of obstruction. At the 
autopsy, a portion of the small intestine with its mesentery 
was found twisted upon its axis, from right to left, without 
any marked evidence of inflammation. 
(c) Substances which have been swallowed, or substances 
whose nuclei have been swallowed, and which consist of a 
deposit of carbonate and phosphate of lime, or substances 
which have been produced entirely in the system, and which 
lodged in narrow parts of the intestine, cause obstruction. 
Such substances, some of which occur most frequently in chil- 
dren, and others in elderly people, produce acute constipation. 
Indigestible matter contained in the food, as seeds or the 
parenchymatous portions of fruits, occasionally collect in con- 
siderable quantity and obstruct the intestine. A large gall- 
stone, having escaped from the common bile-duct, occasionally 
obstructs the intestine, either at the ileo-cecal valve or, more 
rarely, at some bther point. But this seldom occurs in 
children. 
In one instance, and in only one, have I known obstinate 
constipation to be produced by worms. The patient was a 
girl of about four years, in whom constipation came on sud- 
denly, and was accompanied by distention of abdomen and 
great suffering. This continued nearly one week, when a mass 
of intertwined round worms was expelled with immediate 
relief. The records of medicine also contain cases in which 
neoplasms, growing from the coats of the intestines internally, 
have attained such size as to retard the evacuations. 
(d) Abscesses and tumors, especially when occurring in the 
pelvis, also sometimes cause constipation by pressing upon the 
intestine, and obstructing or narrowing the passage through it. 68 
Smith: Constipation in Children. 
Thus, in 1868, Mr. Thomas Smith related to the London Path. 
Society the case of an infant, aged fourteen months, in whom 
both alvine and urinary evacuations were retarded by a cancer- 
ous tumor growing between the rectum and bladder, and end- 
ing fatally in three months after the occurrence of the first 
symptoms. 
(e) Peritonitis, during its continuance, is known to consti- 
pate the bowels. It is supposed that inflammatory edema 
occurs around the muscular fibres of the middle coat, by which 
their contractility is impaired. Hence the lax state, the 
meteorism, and inaction of the intestines in this disease. When 
the peritonitis abates, the normal action is restored, and the 
evacuations occur regularly, if the free surface of the perito- 
neum have undergone no unfavorable change. But unfortunately 
peritonitis often produces more lasting injury, so as to interfere 
seriously with the intestinal movements, and produce an habi- 
tually torpid state of the bowels. This occurs from adventitious 
bands of inflammatory origin, which lie across the intestines, 
compressing them at the points of contact, and restraining their 
movements, and from adhesion of the intestinal loops. 
The most marked cases which I have observed of this were 
children who had had tubercular peritonitis. The following 
was an interesting example: 
Charles, aged 4 years, was returned to the N. Y. Foundling 
Asylum on April 16th, 1877, to be treated for tumor albus of the 
left knee, and for general ill-health. His parentage and early his- 
tory were unknown. The nurse in the city, to whom he had 
been intrusted when quite small, stated that he had no sick- 
ness when with her, except sore eyes, and that about April 1st, 
1877, the enlargement of the knee was first observed. The head 
of the boy was large, and the abdomen much distended, but with- 
out any decided tenderness on pressure ; its entire lower part had 
a purplish color. Percussion over it gave a dull sound, except 
upon and near the epigastrium, where there was some resonance ; 
umbilicus prominent; circumference of body over abdomen, 23 
inches; pulse 128 ; axillary temperature 99°. It was stated 
that he had no stool without medicine, and that, usually, one 
tablespoonful of castor oil was required to produce it. The urine 
contained no albumen, and was apparently normal. As the 
appearance indicated struma, a mixture of cod-liver oil, syrup of 
the lacto-phosphate of lime, and iron was prescribed, to be given 
three times daily, and directions were given to rub cod-liver oil 
over the abdomen also three times each day, for five minutes 
each time. Some nodules were felt, on pressure upon the abdo- Smith : Constipation in Children. 
69 
men, which we suspected were enlarged mesenteric glands. From 
the day on which the friction and kneading of the abdomen was 
commenced, the stools began to occur, in the average, about twice 
daily. The kneading proved the safest, as wTell as most efficient, 
method of producing defecation. 
On May 4th, the circumference of the trunk over the most 
prominent part of the abdomen was reduced to twenty-two inches. 
The records on May 11th state : “same treatment is continued ; 
has tolerable appetite, but is pallid, and his flesh flabby and soft.” 
On May 22d, the circumference of the trunk gave 22f inches. 
The tumor albus remained about the same. 
I saw the patient again during attendance in the asylum, in 
August and November. The record in November states that he 
is feeble and failing ; is becoming weaker and thinner; breath 
and exhalations from the surface offensive; he is kept quiet on 
account of the knee. From this time he gradually failed, and 
died April 11th, 1878. There was no cough to attract attention ; 
and instead of constipation, a diarrhea of some weeks’ continu- 
ance preceded death. 
Autopsy.—Lungs healthy, except a little exudation over the 
summit of right lung; bronchial glands cheesy; numerous tu- 
bercles, some of them cheesy, upon the parietal and visceral sur- 
face of the peritoneum. Loops of the intestines were united to 
each other by old adhesions, and the small intestines were gen- 
erally bound down by bands into a “ uniform conglomeration 
mesenteric glands enlarged and cheesy ; a large ulcer upon the sur- 
face of the rectum, and numerous small, round ulcers upon the 
surface of small and large intestines, apparently occupying the 
site of the lymph follicles. 
Occasionally, a false band, the result of peritonitis, lies across 
the intestines, without restraining their movements, and pro- 
ducing no marked symptoms, and probably no symptoms at all, 
until a loop happens to pass underneath it, when, if not soon 
released, it is apt to become strangulated, with complete 
obstruction to the passage of fecal matter. This displacement 
might properly be classified with the internal hernias described 
above. In my own person, at the age of twelve years, such an 
accident occurred about two months after the peritonitis. 
Upon the abatement of the inflammation, a sensation of trac- 
tion had been noticed in the umbilical region, almost daily 
during exercise, and the displacement was indicated by the 
extreme pain which characterizes such cases, and which 
ceased suddenly, when the parts were released after about 
eighteen hours. 
Idiopathic Constipation. Causes.—These are quite numer- 70 
Smith : Constipation in Children. 
ous. The more prominent of them are the following. First, 
too little liquid in the excrement, so that it is too firm for 
ready evacuation. There may be too little liquid taken in the 
ingesta, or too scanty secretion of the liquids which mix with 
the food, as those of the pancreas, liver, and mucous follicles, 
or there may be too great an absorption of liquid through the 
coats of the intestines and too active an excretion of water 
from the skin, kidneys, or lung. The firmer the fecal matter 
the greater the tendency to constipation. Those who lose a 
large amount of water, as in diabetes, night sweats, or from 
occupations which expose to heat, or from residence in a hot 
climate, are especially liable to constipation, except as the loss, 
of liquid is compensated by an increased amount of drink. 
The character of the food, apart from the amount of liquid 
which it contains, obviously has a marked influence upon the 
consistence and frequency of the stools. Occasionally, the 
intestines act sluggishly from insufficiency of food. Thus, the 
infant sometimes hangs an unusually long time on the breast, 
and the mother or wet-nurse believes it to be a hearty 
nurser, when there is really deficiency of milk, and the stools 
are scanty and infrequent from lack of material. Again, con- 
stipation is not uncommon in infants who nurse heartily, and 
seem to obtain a sufficient quantity of milk, and the cause of 
it is not in the state of the digestive organs, but in the milk. 
We find that now and then breast-milk has a constipating 
effect, although we discover nothing to cause this result in the 
mother’s diet or health. The comparison of ordinary milk 
with colostrum may furnish a clue to the explanation. Colos- 
trum is known to be more laxative than ordinary milk, and it 
differs from it chemically in containing more butter, sugar, 
and salts. Hence the theory seems plausible that, when breast- 
milk is constipating, these elements occur in less than the nor- 
mal quantity. And we shall see hereafter that treatment sug- 
gested by this theory obviates the constipation. 
The use of a diet which consists chiefly of assimilable sub- 
stances, as animal food, and from which, after the digestive 
process, little coarse and stimulating residuum remains, is 
obviously apt to produce a sluggish state of the bowels. On 
the other hand, coarse food, as fruits with their seeds, coarsely 
ground meal, etc., which stimulate the peristaltic action and Smith : Constipation in Children. 
71 
the secretions, increase the number and frequency of the alvine 
discharges. 
Habit also exerts a decided influence upon defecation. One 
who, for whatever reason, neglects or resists the desire for a 
stool, soon becomes less conscious of the daily recurring need, 
and establishes a constipated habit. Constipation is more apt 
to occur in those who lead a quiet life than in those who are 
active. This is probably a more frequent cause of constipation 
among school children than is commonly supposed. 
While it is important that the diet and glandular secretions 
should be such that the feculent matter has proper consistence, 
for easy propulsion along the intestinal tube, the important 
agent by which alvine evacuations are effected is obviously 
muscular contraction. The muscular fibres of the intestines 
produce the vermicular and peristaltic movements, by which 
the excrement is carried forward, and the abdominal muscles, 
by their powerful contraction, are the chief agents of expul- 
sion. Now any pathological state which impairs the innerva- 
tion of these muscles, or renders it abnormal, destroying the 
proper balance between “exciting and inhibiting impulses,” is 
apt to cause constipation. Hence meningitis, myelitis, and 
certain other diseases of the cerebro-spinal axis, especially 
such as cause paraplegic symptoms, are commonly attended by 
a sluggish state of the intestines, either from tonic contraction 
of the muscular fibres of the middle coat, as in meningitis, or 
paralysis of them. 
But there are cases in which there seems to be a constitu- 
tional tendency to constipation—a tendency quite independent 
of the usual conditions. Thus I have met children who were 
bright and active, free from obstruction or disease which 
might retard the evacuations, apparently far from having slug- 
gish muscular contractility, and so far as I could see with pro- 
per diet, and yet with defecation, except as it was produced by 
measures employed, occurring no oftener than each second, 
third, or fourth day. 
But it must be borne in mind that wliat is constipation in 
one child may not be in another, for occasionally one does 
well with only one evacuation every second or third day, while 
a large majority require daily defecation, in order to the main- 
tenance of perfect health. 72 
Smith : Constipation in Children. 
In the adult, the saceuli or pouches which occur in the walls 
of the colon, produced by contraction of the longitudinal bands, 
acting at right angles to the direction of the circular fibres, and 
consisting of the internal and external tunics, without the mus- 
cular, become the receptacles for fecal matter in those who are 
constipated, and obviously tend to increase the constipation. 
In children these sacculi are much less developed relatively, 
and in young infants, whose intestines lack the longitudinal 
bands, are absent, so that this anatomical condition by which 
the passage of fecal matter is delayed, is unimportant as a 
cause of constipation in the young. 
Constipation has a tendency to perpetuate itself, since re- 
tained feculent matter becomes more consistent and firmer, 
and the contractile power of the muscular tunic becomes weak- 
ened by long distention. Obviously, also, an abnormal length 
of the large intestine, so that it doubles on itself, whether con- 
genital or the result of constipation, and a malposition, which 
diminishes the space occupied by the colon, and therefore in- 
creases its flexures, have a tendency to produce constipation. 
Symptoms.—When there is a mechanical cause, which re- 
tards the passage of fecal matter, the acuteness of symptoms 
and the suffering are generally proportionate to the degree of 
obstruction. Symptomatic constipation occurring in an obstruc- 
tive disease, whether adhesions, peritoneal bands, intussuscep- 
tion, knots or twisting of the intestine, incarceration in a false 
passage, or from biliary or intestinal stones, or fecal masses, 
is attended by severe symptoms, such as intense colicky pain, 
vomiting, loss of appetite, and rapid prostration. The ingesta 
accumulate above the point of obstruction, producing distention 
of the intestine with fecal matter and gas, while below the point 
of obstruction the intestine is soon empty. The symptoms 
indeed have the severity, and the state involves the danger, 
present in ordinary strangulated hernia; while, from being in- 
ternal and therefore less accessible for treatment, the danger 
is even greater. If the intestinal tract is narrowed, whether 
by a false ligament, the result of an old peritonitis, or other 
cause, and there is still perviousness, so that excrementitious 
matter passes by the obstruction, though slowly, and with 
more or less difficulty, the patient may be comparatively com- 
fortable, if the food be such that no hard masses remain ; but Smith : Constipation in Children. 
73 
according to the degree of stenosis, and the amount and coarse- 
ness of the fecal matter, symptoms occur referable to the 
obstruction. If the excrement is propelled with difficulty 
through the narrowed part, the muscular coat above the 
obstruction gradually becomes more developed, from hypertro- 
phy of the muscular fibres, just as the heart enlarges from 
obstructive disease of its valves, while below the obstruction 
the intestine atrophies, and its calibre diminishes from disuse. 
Colicky pains, accumulation of fecal matter above the obstruc- 
tion, distention of abdomen, eructation of gas, vomiting, 
impaired appetite, and consequent decline of the general health 
are common results. There is constant danger in these cases 
that the narrow passage may become obstructed by fecal mat- 
ter, if it happen to contain hard masses, or coarse indigestible 
substances. The gravest form of constipation is obviously 
that due to mechanical agencies which act as obstacles, but as 
the obstacles are numerous, differently located, and of different 
character, so there is great difference in the gravity of the 
cases. 
Idiopathic constipation generally comes on gradually. It at 
first attracts little attention and is neglected. The symptoms, 
of course, vary greatly according to the degree and stage of 
constipation. In mild cases, the retention is only in the rectum, 
or rectum and sigmoid flexure, and there are no marked symp- 
toms except a sensation of fulness or distention of these parts, 
which one or two evacuations relieve. Between these mild 
cases and the graver forms of constipation, there is every inter- 
mediate grade, attended by symptoms proportionately severe. 
It is surprising sometimes to observe how long patients live 
with extreme constipation, though with constant suffering and 
ill-health. And, which I wish especially to be noticed in this 
connection, a large proportion of the fatal cases of idiopathic 
constipation occurring in adults, and recorded in the literature 
of the profession, began early in life, even in infancy, at which 
time they probably might have been relieved by proper reme- 
dial measures, and a life of suffering prevented. This impor- 
tant practical fact shows the need of greater attention on the 
part of parents and nurses to the state of the bowels in children, 
that their sluggish action may be corrected before it becomes 
habitual, and those anatomical changes of distention and mus- 74 
Smith : Constipation in Children. 
cular paralysis occur, which are with difficulty corrected. Thus 
among the older authenticated cases is one related by Dr. Cop- 
land, in his medical dictionary, from Renauldin. 
A medical officer in the French service was always costive from 
birth, he ate largely, but seldom passed a stool oftener than once 
in one or two months, and his abdomen assumed a large size. At 
the age of forty-two, his constipation was usually prolonged to 
three or four months. In 1806, after medicines had been taken 
to procure a stool, which had not been passed for upward of four 
months, abundant evacuations continued for nine days, and con- 
tained the stones of raisins taken a twelvemonth before; but the 
constipation returned. In 1809, the enlarged abdomen became 
painful, vomiting supervened, and he died at the age of fifty-four, 
having seldom, through life, passed more than four, five, or six 
stools in the year. On opening the abdomen, a fibrous partition 
obstructed the rectum, about an inch from the anus. 
A case quite as remarkable, and of recent date, occurred in 
the practice of Dr. Strong, of Westfield, N. Y., and was reported 
by him in the Amer. Journ. of Med. Sei. in 1874 and 1876. 
This patient, at the age of two years, usually had one stool in 
two weeks, and several years later only one in six weeks. When 
an adult he was treated by Dr. Strong, who found great disten- 
tion of the abdomen, so that the lower ribs were pressed outward 
in nearly a horizontal direction, and the thoracic organs upward 
so that the apex beat of the heart was about one inch above the 
nipple. At this time, months elapsed between the stools, the 
longest interval being eight months and sixteen days. Defecation 
when it did occur lasted from two to four days, and was attended 
by violent gastric and intestinal pain, vomiting and prostration. 
At one of these prolonged stools, forty pounds of feces, resembling, 
as it usually did, chewed brown paper, were evacuated, the quan- 
tity being accurately ascertained by weighing the patient before 
and afterwards. He had appetite and was able to do certain 
kinds of farm work during the year preceding his death, which 
occurred at the age of twenty-eight years. At the autopsy the 
colon was found to have a length of six feet and three inches, and 
a circumference of thirteen inches, while the lungs were pressed 
upward and backward, as when compressed by a pleuritic exuda- 
tion. 
While such extreme cases are infrequent, all physicians of ex- 
perience are consulted from time to time by adults who have 
had habitual constipation from their earliest recollection, and 
these cases, that aggregate so large a number, might, there is. 
little reason to doubt, have been prevented for the most part 
during childhood, when the habit was being formed. Smith : Constipation in Children. 
75 
In long-continued constipation, in which there is a large 
fecal accumulation, not only is the diameter of the colon in- 
creased, as stated above, but this part of the intestine becomes 
elongated. This may lead to change in its position, the curves 
of the sigmoid flexure extending further to the right, and the 
central part of the transverse colon by its weight curving 
downward. This abnormal lengthening and the consequent 
curvatures have a tendency to increase the constipation, as 
has been stated above in our remarks relating to the etiology. 
In these cases of extreme constipation, which, fortunately, 
are rare in children, as they are also in adults, the distention 
of the colon at the ileo-cecal orifice has a tendency to widen 
this orifice, so that the valve which, in the ordinary state, pre- 
vents the return of any substance which has once passed by it, 
is apt to become insufficient. The adjacent folds which constitute 
the valve become separated, so that, if vomiting and anti-peri- 
staltic movements occur, fecal matter may pass from the colon 
towards the stomach. In aggravated cases, in which there is 
retention of a large amount of fecal matter, distention, muscu- 
lar paralysis, etc., similar to those which we have seen pro- 
duced in the colon, are apt to occur, though to a less extent, in 
the small intestines, especially in the ileum. 
Retained excrementitious matter accumulating in large 
masses evidently becomes an irritant, so that, by its pressure, it 
excites muscular contractions, which, if ineffectual in propelling 
the mass, cause colicky pains. The retained fecal matter also 
undergoes more or less decomposition, producing gases which, 
by increasing the distention, also increase the pain. 
Any irritating substance applied to a mucous surface is apt 
to excite increased secretion from the mucous follicles or from 
the glands whose orifices connect with the mucous membrane 
at the point of irritation. Many familiar examples will at 
once be recalled to mind, as the defluxion from the nostrils 
from the use of snuffs, and increased mucous secretion and 
salivation from objects held in the mouth. In the same way, 
retained excrement, forming hard masses which press upon the 
intestinal surface, excite a secretion, and not infrequently pro- 
duce thereby a diarrhea which is conservative, and which may 
for the time unload the bowels, or it may remove a part of the 
scybalse, while the rest remain. Hence we sometimes hear 76 
Smith : Constipation in Children. 
patients speak of having irregular evacuations, constipation 
alternating with diarrhea. In aggravated cases, the pressure 
of impacted feces sometimes produces inflammation of the 
surface, when, in addition to abdominal pain, there are tender- 
ness on pressure and some, usually quite moderate, febrile 
movement. In cases which have terminated fatally, after a 
longer or shorter time, destruction of the mucous surface has 
been found in places, in consequence of the pressure and 
inflammation. Thus, in the history of the French officer 
related above, it is stated that the inner surface of the distended 
intestine “ presented gangrenous and ulcerated patches.” We 
can readily believe that, as in cases of typhoid ulcerations, if 
the ulcers reach a certain depth, they may also give rise to 
localized peritonitis, and that occasionally perforation may re- 
sult at the ulcerated or gangrenous point. The expulsion of 
hardened masses which have collected in the rectum is slow 
and painful, and accompanied by more or less tenesmus, which 
not infrequently causes a portion of the mucous membrane at 
the anal orifice to descend below the sphincter ani and pro- 
trude, by which hemorrhoids are produced. Occasionally, as 
I have observed in certain cases, the entire circumference 
of the rectal mucous membrane, to the distance of half an 
inch or more above the anus, becomes so loosened from its 
attachment to the connective tissue that it descends below the 
sphincter ani, and protrudes during each defecation. But this 
displacement, known as prolapsus recti, more commonly results, 
in children, from protracted intestinal catarrh, attended by 
diarrhea, loss of flesh, and by diminished tonicity of the tissues. 
A beautiful and conservative provision in the system is that 
by which vicarious functions are established to relieve organs 
which imperfectly perform their part. While the intestinal 
surface is to a great degree eliminative, so that noxious and 
effete products are largely expelled from the system in the 
stools, it possesses also, in high degree, an absorbent function, 
as all who employ rectal alimentation are aware. Now, if the 
intestine fail to perform its function of defecation, and feculent 
matter collect within it, and begin to exert pressure upon the 
intestinal surface, more or less of the liquid portion is taken up 
by the vessels, and, entering the general circulation, finds a 
mode of escape through other emunctories. The general ill- Smith : Constipation in Children. 
77 
health or languor, the furred tongue, headache, and foul breath 
which characterize these cases are, no doubt, due to the ab- 
sorption into the blood, or retention in it of noxious products 
contained in, and which in part constitute, the feculent mat- 
ter. The fact that patients may live for years with tolerable 
appetite, and with only one dejection every second or third 
week, receives explanation in the fact that other organs, as the 
lungs, kidneys, skin, etc., act as depurants for such excremen- 
titious matter as can be taken up in a liquid or gaseous form by 
the intestinal surface. 
In infants, constipation, even when slight and temporary, often 
causes fretfulness, which is indicated by the character of their 
cries and the movement of the thighs over the abdomen. Con- 
tinuing for a time, it causes more or less fever, and, in those 
young children who are liable to eclampsia, it predisposes to 
an attack, and it may be the chief cause. 
Treatment.—If there is reason to suspect the presence of a 
mechanical obstacle which prevents normal defecation, a care- 
ful examination should be made, in order to discover, if pos- 
sible, its nature and location. Often it is of such a nature that 
it cannot be removed, but its constipating effects may some- 
times be in a measure obviated. In the case related above, in 
which constipation continued from early childhood to adult 
life, and finally proved fatal, its cause was ascertained to be a 
septum in the rectum, which probably might have been 
relieved by surgical measures. In all cases of constipation, 
which the history shows may be produced by mechanical 
causes, whether the obstruction is complete and the colicky 
pains and other symptoms severe, or there are occasional 
scanty evacuations, with but slight or moderate suffering, the 
history of the patient should be obtained, in order to ascertain 
if there had been at any previous time symptoms of peritonitis 
or other pathological state which might throw light on the 
etiology. The abdomen and the usual sites of hernia should 
be carefully explored by palpation, and the rectum by the 
finger, large-size catheter, or rectal tube. A thorough examin- 
ation thus instituted, painless to the patient, will usually en- 
able the practitioner to determine either the exact or probable 
obstacle, if any be present. 
The proper treatment of symptomatic constipation obviously 78 
Smith: Constipation in Children. 
requires the removal, so far as possible, of the primary disease, 
or the cause, whether it be obstructive or otherwise, and we 
need not stop to consider the special measures which are re- 
quired, and will pass to the consideration of the treatment of 
idiopathic constipation. 
Hygienic Measures.—We have already alluded to the fact 
that habit has a powerful control over the action of the intes- 
tines, so that it is important to obtain a daily alvine evacuation 
at a certain hour, and, by establishing the habit, the need will 
usually be experienced when that hour arrives each day. 
Many cases which become troublesome and obstinate might, 
no doubt, have been prevented, had this physiological law been 
heeded, add a daily evacuation obtained at a certain hour. 
The constipated habit, mild and not yet fully established, is 
more apt to be overlooked when it occurs in childhood than in in- 
fancy, for the infant is closely and constantly under observation, 
and it soon presents symptoms, as fever and fretfulness, if it 
do not have the regular evacuation, while children over the 
age of four to five years tolerate better a sluggish state of the 
bowels, and are likely to be constipated for a considerable 
time before it is ascertained. They therefore require more 
attention, in this regard, than is usually bestowed by parents. 
The nature of the diet is obviously important, as certain 
kinds of food are more laxative than others. Chicken-tea and, 
to a certain extent, beef and mutton tea are laxative, and, made 
plainly, are, therefore, useful in connection with other articles. 
The various kinds of berries and fruits have also a decidedly 
stimulating effect on the intestinal surface, and aid in remov- 
ing constipation. The apple, scraped or baked, or apple- 
sauce, may be given to quite young children; and for those 
that are older, currants, cherries, and, among dried fruits, prunes 
and figs are laxative. Unfennented cider, in its season, which 
has been found so useful for adults, may also be given to chil- 
dren in moderate quantity, at least to those who have reached 
the age of two or three years. 
By the digestive process, starch, which is unassimilable, is 
changed into glucose, which can be absorbed and assimilated, 
and, from the small size of the salivary glands in the first 
months of infancy, it is believed that the salivary and pancreatic 
fluids are insufficient to convert starch into glucose, except in Smith : Constipation in Children. 
79 
very inadequate quantity. It appears, however, highly prob- 
able that there is an epithelial ferment, which converts starch 
into sugar (see Chemical Phenomena of Digestion, by Charles 
Riehet, Rev. des Sci. Med., Oct., 1878), so that young infants 
can digest starchy food. Nevertheless, the theory that the in- 
fantile digestion, up to a certain age, is inadequate to effect the 
change, led to the preparation of food for infants, in which the 
change of starch into glucose was accomplished by a chemical 
process. Now glucose, given in considerable quantity, is lax- 
ative, and I have found it necessary to give the glucose pre- 
paration sparingly, or not at all, during the hot months, when 
infants are so prone to diarrhea. But this laxative effect ren- 
ders the glucose preparations of the shops very useful in the 
treatment of habitual constipation of infants, whether we 
employ the “maltose ” or “ granulated sugar of malt,” or the 
preparations of Liebig’s food. Of four constipated infants in 
the New York Infant Asylum, to whom Horlick’s “ sugar of 
malt ” was given, three were relieved. Any of the glucose 
preparations can be given quite freely to a constipated infant, 
without impairing the digestive function, or producing other 
ill-effect, so long as no more than the normal evacuations are 
produced ; and I consider them among the best and safest of 
the foods for the relief of constipation in infants, but glu- 
cose or grape sugar is only feebly laxative, probably not more 
than cane sugar. 
Oatmeal is more laxative than most other kinds of amylaceous 
food. Made into a gruel and strained, it may be given to the 
nursing infant, and unstrained to those who are older. Bread 
or pudding from coarsely-ground or unbolted flour or meal, and 
vegetables which contain saline and fibrous substances, have a 
stimulating and laxative effect on the surface of the intestines, 
and, therefore, are useful for constipated children of the age of 
two or three years and upward. 
There can be no doubt that the free use of water in the 
ingesta materially aids in relieving costiveness. In one of the 
numbers of the London Lancet, a physician asks the profes- 
sion how to cure obstinate constipation in adults. Among the 
replies, one physician suggests drinking a tumblerful of cold 
water on retiring to bed, and another tumblerful in the morning, 
and there can, I think, be little doubt that the laxative effect 80 
Smith : Constipation in Children. 
of the broths, gruels, fruits, and mineral waters is partly due to 
the amount of water which they contain. One of the chief 
causes of constipation we have seen is too great firmness or 
consistence of the stools, due to absorption of the water, and if 
a larger quantity of water is swallowed during or after the 
meals than is removed by absorption, so that the stools have 
their normal or less than normal consistence, this cause of con- 
stipation is removed. An excess of water introduced into the 
system is to a great extent eliminated by the kidneys, and, in 
hot weather, by the skin, and, to a certain extent, exhaled from 
the lungs; but experience shows that, if the amount of liquid 
received is so great that the vessels in the coats of the intest- 
ines continue in a state of repletion, only a certain part of it 
is absorbed, while the rest descends and mixes wTith the excre- 
mentitious matter. 
This simple expedient of allowing a liberal use of water, so 
useful in adult cases, doubtless also has a laxative effect in 
children, and its judicious use is proper for them. Another 
important aid in overcoming habitual constipation is frequent 
kneading of the abdomen. My attention was first particu- 
larly directed to this in the treatment of the case related 
above, in which obstinate constipation, occurring in a child of 
three years from peritoneal bands and adhesions, was to a 
great extent corrected by friction over the abdomen for three or 
four minutes at a time with cod-liver oil, and three or four 
times daily. The manipulation probably did the good, and 
not the oil, but the use of one of the oils for inunction renders 
the kneading less painful, and insures its more thorough per- 
formance by the nurse. All obstetricians in certain emergen- 
cies stimulate the uterine muscular fibres to contraction by 
kneading the abdomen, and it is probable that the muscular 
fibres of the intestines are stimulated in a similar manner, so 
that the intestinal movements are increased by which feculent 
matter is carried forward. 
The external application of cold, so effectual in contracting 
the uterine muscular fibres, also stimulates the contractile 
power of the muscular fibres of the intestines. Cold-water 
bathing, the sudden application of a cloth wrung out of cold 
water to the abdomen, and in certain obstinate cases even the 
douche may bp used to stimulate the muscular coat of the Smith: Constipation in Children. 
81 
intestines, and the abdominal muscles, to greater activity 
Trousseau says: “Before leaving the subject of the treatment 
of constipation, let me refer to the application of cold to the 
abdomen—a minor method which I have seen recommended, 
and have myself prescribed with astonishing success. On ris- 
ing in the morning, let there be placed on the abdomen a 
compress of several folds soaked in cold wTater, and let it be 
separated from the clothes by a sheet of gutta percha or caout- 
chouc. This compress ought to remain on for three or four 
hours.” This recommendation by Trousseau is for adults, 
who are much less susceptible to the influence of cold than 
children. So prolonged an application of cold and wet to a 
child, even the most robust, would involve danger, while its 
application during the brief period occupied in an ordinary 
bath, with proper exercise afterwards, or with other measures 
to prevent chilling, could have no ill-effect. 
Therapeutic Measures.—For temporary constipation and 
many cases that are habitual, enemata should be employed, 
since they promptly unload that part of the intestines in which 
feculent matter is ordinarily retained, while they do not impair 
the appetite or produce the prostration which so often results 
from purgatives. For temporary constipation, a warm clyster 
may be given, and it commonly is more agreeable to the 
patient than one of lower temperature than the body. Among 
the enemata which have been found useful are castile soap 
with molasses and water, salt and water, the various oils, as 
sweet oil, with or without castor oil 4 linseed oil, alone or with 
molasses, and the gruels, as that of oat-meal or corn-meal made 
thin. The belief that the frequent use of warm clysters pro- 
duces a relaxing effect is probably correct, so that, if it is ne- 
cessary to employ clysters often, in consequence of the torpid 
state of the intestines, cool water, the effect of which is tonic 
and stimulating, should be used. 
For infants, a clyster of one or two ounces usually suffices, 
administered by a gutta perclia or glass syringe, while for 
older patients a proportionately larger quantity is required, 
administered by preference through a Davidson India-rubber or 
a fountain syringe. In certain long-continued, aggravated cases, 
the frequent injection of a large quantity of tepid water is 
indispensable, in order to wash away the accumulation of fecal 82 
Smith: Constipation in Children. 
matter. Thus, in 1854, Mr. Gay exhibited to the London 
Pathological Society a boy of seven years, who at the age of 
three years had had typhus fever with dysenteric stools. 
After convalescence, he had habitual obstinate constipation, so 
that, when Mr. Gay began treatment, there had been no fecal 
evacuation for nearly four months, and the girth of the body 
over the abdomen was forty-nine inches, and yet the appetite 
and general health were not seriously impaired. The shape of 
the abdomen and the examination showed great distention of 
the rectal ampulla and the descending colon. Mr. Gay first dis- 
tended the sphincter ani, so that it admitted a speculum, and 
through a rectal tube, well introduced into the colon, the 
excrement was repeatedly washed away, so that at the time of 
the exhibition of the boy to the Society, the measurement in 
girth gave only twenty-four inches. Evidently in cases like 
the above, no other treatment except repeatedly washing out 
the intestines with warm water would have answered, and the 
dilatation of the sphincter ani and the introduction of the spec- 
ulum to facilitate the escape of fecal matter are noteworthy. 
Suppositories may sometimes be usefully employed in place 
of enemata; cocoanut butter, molasses candy, or soap cut in 
shape of a pencil may be used for this purpose. In the adult, 
long-continued constipation is not very rare, in which the 
rectal ampulla becomes so impacted that it is necessary to use 
the anal curette, the handle of a spoon, or the finger intro- 
duced, in order to break up the masses, and allow them to pass. 
In children, necessity for such treatment is much more rare, 
but there are occasionally cases like that above described by 
Mr. Gay, in which it may be needed. Dr. Nagel states that 
the evil may be removed by the introduction of a suppository 
of brown gelatine. This is steeped in water for twelve hours, 
and having been thus softened, is introduced into the rectum, 
and an evacuation obtained. The doctor attributes the laxa- 
tive effect to the hygrometric action of the gelatine. 
The known effect of the galvanic current in producing con- 
traction of the uterine muscular fibre suggests its employment 
to relieve constipation, by stimulating the muscles of the abdo- 
men and the muscular coats of the intestines, and those who 
have employed it speak favorably of its use. Habershon 
says: “ A galvanic current, transmitted through the abdominal Smith: Constipation in Children. 
walls, induces a very speedy action, or rather emptying of the 
colon. ... A case of partial paraplegia, in which injections 
did not act satisfactorily, and drastic purgatives were unde- 
sirable, was treated by a galvanic current passed through the 
abdomen every morning. In a few hours a free evacuation was 
produced without any discomfort.” But the constipation of 
children very seldom requires the use of galvanism. 
The ordinary purgatives should not be given habitually to re- 
lieve a constipated habit. They are apt to irritate the intestines, 
causing a catarrh, or else the intestines become accustomed to 
their action, and a large dose is needed to effect purgation. 
Given habitually, they cannot fail, also, to disturb the digestive 
and nutritive processes. One or two doses for present relief, 
both in habitual or temporary constipation, is sometimes 
required, provided that an injection is for any reason not pre- 
ferred. For this purpose, castor oil or a few grains of calomel 
mixed with syrup of rhubarb, the syrup of senna, or the com- 
pound liquorice-powder of the German Pharm. may be adminis- 
tered with advantage. But for habitual constipation I strongly 
advise to discard the ordinary purgative medicines, and if 
the measures of a dietetic or hygienic character, recom- 
mended above, are not sufficient, to employ such remedial 
agents as promote, or at least do not impair nutrition. 
Belladonna, so highly recommended by Trousseau and 
others, I have often administered to children, especially in 
pertussis, in large doses during several consecutive days, and 
it has not seemed to me to have any decided purgative effect. 
Though it may be useful in certain mixtures for adults, our 
experiences in this country, with reliable preparations, certainly 
have not been such as to justify its employment as the sole or 
main remedy for constipation. It diminishes reflex irritabil- 
ity, and may render the action of purgatives less painful, but 
from its known physiological effects we cannot believe that 
it increases the intestinal secretions or the action of the mus- 
cular fibres, one or the other of which results, we expect, from 
the use of an agent which is really laxative. Why the effects 
of belladonna, in this country, differ so widely from those observ- 
ed abroad, needs explanation. On the other hand, nux vomica 
and its active principle, strychnia, are doubtless valuble adjuncts 84 
Smith : Constipation in Children. 
to purgative mixtures from their effect in increasing the action 
of muscular fibres. 
Physicians are not infrequently at a loss what to prescribe 
for the habitual constipation of nursing infants, which is by 
no means infrequent. But recollecting that the colostrum is 
more laxative than ordinary milk, and that it differs from it 
in containing more sugar, salts (largely phosphates), and but- 
ter, we have a hint, as stated above, as to what is probably 
lacking in the milk, and what, therefore, should be supplied. 
I am in the habit of giving the oil, sugar, and salts in the fol- 
lowing formula, and usually with the desired laxative effect. 
01. morrhuae 2 parts. 
Aq. calcis, 
Syr. calcis lactoplios aa. 1 part. 
One-quarter, one-third, or one-half teaspoonful may be given 
with each nursing, or a larger quantity, as a teaspoonful or more, 
three times daily. Breast-milk with this addition becomes 
more nearly like colostrum in its laxative properties, while it 
does not possess those properties of colostrum which disturb 
the digestive process. I know no agent of a medicinal nature 
which meets the indication so well as this for infantile consti- 
pation. But in my practice I have found it necessary, in not 
a few instances, to rely mainly on simple enemata for the re- 
lief of the constipated habit, till the infants reached the age 
when a mixed diet was proper. 
The habitual constipation of older children may ordinarily 
be relieved by the remedies recommended above, but occasion- 
ally a more active purgative effect may be needed. Since the 
portion of intestine which is chiefly implicated in ordinary 
forms of constipation is the colon, it is evident that, if it is 
necessary to employ frequently any of the active purgatives of 
the pharmacopeia, such should be selected as produce little or 
no irritation of the long tract of the small intestines, while 
they stimulate the function of the colon. The aloetic prepara- 
tions are preferable for this purpose, as the tincture of aloes, 
and myrrh, or the simple tincture of aloes, which may be given 
in dose of part of a teaspoonful in a convenient syrup, as the 
elixir adjuvans of Caswell & Hazard, or in coffee or milk. 
227 West 49th St.