CONSTIPATION IN OLDER CHILDREN It has been shown, in the discussion of Hirschsprung's disease, that in early childhood there exists a certain anatomical disposition to constipation, which has again been recently studied by Saias. He ac counts for it by the relative length of the colon in proportion to that of the small intestines, the laxity of its mesentery, the winding course and the twists of the sigmoid flexure, and by the lessened development of the musele-layers and of the elastic tissue. The hindrance of the stools from reflex causes. such as exeoriations and fissures of the anus, which because of their sensitiveness in 'defecation, occasion retention of feces in a child, has already been mentioned. Further reasons for constipation are seen in the kind of nourishment after early infancy, and Czerny has properly called attention to the influence, in this regard, of the so-called "strengthening diet" which consists particularly of milk, meat and eggs. The foods especially suited to stimulate peris talsis, such as bread, potatoes, green N egetables, are, in this diet, wholly neglected, or given in an entirely insufficient quantity. There should be added as a further source of constipation, the wide-spread custom of giving very large quantities of cow's milk as a beverage.
addition to this alimentary constipation in older children, there are cases in which a hindrance to the passage of stools occurs, notwithstanding a rational diet given in proper quantities and at suitable intervals. This must be accounted for because of anatomical peculiarities in the structure of the intestine, or is due to a congenital malposition.
In school children the hurried leaving of the house, in the niorning, means that they do not take a sufficient time to visit the closet, or do not remain there long enough, so that either no stool or one quite un satisfactory is effected at the usual hour. In girls, later in life, a false sense of modesty plays a rOle at times as does the manner of dressing; and, especially in the female sex, the use of corsets acts as a restraint upon the rnoveinents of the abdomen. In addition may be mentioned
the manner of living, and the sitting posture to which the school children are condemned in our present educational methods, which leads to anmmie conditions in consequence of which intestinal atrophy sets in. That catarrh of the intestinal tract, particularly colitis, can be followed by persistent constipation, has already been referred to. I would like also to point out the costive condition which may follow the exclusive milk diet after scarlet fever.
One dares not rely upon the statement of the attendant, or of the child itself, that it has a daily stool, as there are many cases who may have a passage each morning which is only partially effectual, and so they may in time suffer all the consequences of chronic constipation.
On the other hand, there are others who have no stool for a period of days or a week (the longest such interval in my personal experience concerned a child of six years and was for twelve clays); and, filially, there are individuals in whom periods of normal defecation alternate with those of persistent constipation.
The feces appear usually very dark (a.s though scorched); they are dry, often covered by mucous strands, or are hard and round like goat droppings; they are evacuated during hard abdominal straining. The child plants its legs firmly on the ground, and the deeply congested face, covered with sweat, betrays the greatest exertion. S.jniall clrops or streaks of blood may be present in the movement, produced by the injury of the mucous membrane of the large intestine by the hard fecal masses. Very often it is not possible with the greatest straining to press out the scybala, and the process must be helped with the fingers.
The abdomen, in such cases, is rarely distended, so that it is possible in relaxed abdominal walls to feel the masses collected in the signmid flexure.