If the constipation proceed to actual impaction of fca.l. masses in the bowel, more striking symptoms are noticed. The impaction usually takes place in the rectum itself, and consists of a quantity of hard lumps which it is very difficult to break down and bring away. The presence of the hard masses causes irritation, which shows itself by more or less pain in the lower part of the belly, by tenesmus, and often by difficulty of micturi tion. The child is generally sallow, listless, and weakly-looking. The appe tite may be unaltered, but is usually poor. The tongue is often quite clean, although the breath is foetid. The belly is distended and sometimes tender. Diarrhoea may be a consequence of the intestinal irritation. The motions are scanty and thin ; they usually contain, a few small scybala, and are passed with much pain and tenesmus. Instead of loose, they may be very small and solid, with excess of mucus.
In some cases, in addition to irritation, positive injury may be caused by the presence of the masses. Dr. T. Chambers has reported the case of a girl, aged eleven years, who had suffered for three months from a per sistent diarrhoea which was the consequence of a vast accumulation of faeces in the rectum. The mass by its pressure had caused absorption of the triangular cushion which constitutes the perinum, and had reduced the recto-vaginal septum to a mere membrane.
These cases, if not judiciously treated, may actually prove fatal. Dr. Bristowe has referred to the case of a little girl, eight years old, who had long suffered from a tendency to constipation, and had occasionally gone for three weeks without relief to the bowels. When she came under observa tion she had had no passage for seven weeks. The child was pale and thin, with a strumous look. Her belly was large and tense, although painless, her tongue clean and her appetite poor. She grew weaker, and looked hag gard and anxious. Her belly became more distended, and occasional colicky pains were complained of: Towards the end, her tongue became foul ; she often vomited, passed high-coloured urine in small quantity, and eventually sank from exhaustion. The vomiting was never stercoraceous. After death, the intestines were found greatly distended and their coats hypertrophied. They were full of olive-green, semi-solid which were of thicker con sistence in the rectum than elsewhere ; and immediately above the anus was a hard conical plug of fatal matter which completely prevented the escape of the contents of the bowel.
If impaction take place at a higher point in the bowel—in the mourn or at a bend of the colon—symptoms of complete occlusion may arise, and inflammation is often excited in the intestine. Over the seat of ob struction there is pain, which may extend to the whole abdomen, and be violent and paroxysmal ; there is tenesmus, and the bowels are obstinately confined. The child vomits repeatedly, throwing up at first bile and mu cus, afterwards feculent matter. Hiccough may be distressing. The abdo
men is distended. The tongue is thickly furred, and perhaps dry and brown. The pulse is rapid, small, and thready ; the temperature is often high, and the prostration is extreme. On examination of the belly, a hard swelling, may be detected through the muscular wall, and can often be indented with the finger ; or, if inflammation have occurred, there is some tension of the parietes, and an intensely tender swelling can be discovered at the seat of obstruction. Inflammation of the cFecum (typhlitis) is the most familiar instance of this inflammatory form of the disorder. Firm impaction of the colon with is a variety of obstruction which, if not relieved by the adoption of suitable measures, may be as fatal to the pa tient as any other form of intestinal occlusion, but it is eminently cura ble if the nature of the impediment be recognised in time.
Diagnosis.—In ordinary cases, the want of regularity in defecation, and the infrequent passage of hard, scanty stools, is a sufficient token of the ex istence of constipation. But often the indications are much less precise. In infancy, as has already been remarked, a single stool in the four-and twenty hours constitutes a state of constipation which requires attention. Even in older children a daily evacuation may occur and yet the relief to the bowels be incomplete. Habitual sallowness of complexion, offensive breath, wakefulness at night and startings in sleep, are common indica tions of a loaded bowel, especially if the symptoms occur in a well-nourished child who presents no other indication of ill-health ; and dyspeptic symptoms (discomfort and a feeling of heaviness after meals, occasional nausea and a furred tongue) will often be found to arise from the same condition.
It is very important in cases where the evacuations are very small, fre quent, and watery, or loose, to remember that this condition is often a consequence of the accumulation of fecal masses in the rectum. In such cases, we may expect to find distention of the belly and tenesmus, with some pain in the lower bowel in defecation ; and the stools, on inspec tion, will be found to consist of offensive, thin feculent matter containing mucus and a few small, hard scybalie. When these symptoms are noticed in a child of four or five years of age or upwards, it is of importance to examine the rectum ; and often by this means the cause of the apparent looseness may be discovered at once. Still, even if we obtain evidence of faecal accumulation, caution is often necessary. We must not at once con clude that retained faecal matter constitutes the whole of the derangement, and that when this has been removed the child will be well. Ulceration of the bowels is often accompanied by this very group of symptoms. This subject is considered elsewhere (see page 661).