Habitual constipation is such a common occurrence in infancy and childhood that it warrants a somewhat detailed consideration. The methods that may safely be employed to clear the lower bowel of accumulated faeces, or, in other words, to relieve the actual state of constipation, will be first noticed, for this is always a necessary step when there is painful straining, and in case there has been no movement for a day or more. For this purpose injections are most efficient, and when given with care are entirely free from danger.

A serviceable plan is to inject into the rectum, according to the age of the patient, from one to four teaspoonfuls of warm olive oil; allow it to remain for six hours, and then use one or more injections of normal saline solution. The preliminary injection of oil softens the faeces, while the subsequent ones have the additional effect of distending the walls of the rectum, thus bringing about muscular contraction and expulsion of its contents. Should a compact faecal mass be present at the anus and be too bulky to escape - a condition often visible during straining - more liquid must be injected, and if this fails the mass must be broken up by the finger and its passage assisted by gentle pressure upon the parts behind the anus while expulsive efforts are being made. The process of breaking up is easy, as the anus is widely distended at such times. In obstinate cases little result may follow a single employment of the injections, though a course of one or two oil injections and purgative enemata for several successive days rarely fails to empty the bowel.

The best syringe for children is one of hard rubber with a long, smooth nozzle, having a capacity of six or eight fluidounces. When oil is injected, the intention being to have it remain in the rectum and act mechanically on the faeces, its retention is best secured by firmly pressing a warmed pad of flannel against the anus for five minutes after the insertion, the patient, in the meanwhile, lying upon his back. The laxative enemata must vary in bulk with the age of the child, or, in other words, with the capacity of the rectum; two fluidounces (four tablespoonfuls) will be sufficient for an infant of six weeks, while from four to eight fluidounces are required at the age of two years. The quantity of salt to be used must depend upon the quantity of water - half a teaspoonful of salt to eight ounces of water being the proper proportion. After drawing the fluid - which must be tepid - into the syringe, grease the nozzle well and gently insert it into the anus, directing the point a little toward the patient's left; next slowly force down the piston until all the liquid is expelled or complaints of pain indicate that the bowel is sufficiently distended. If it be possible to secure retention for a moment or two by pressure on the anus, the movement will be freer and easier than if the fluid be allowed to flow away at once. The best positions for the child are either on his back with his legs well drawn up, or resting on his abdomen across the nurse's lap.

Injections of glycerin and glycerin suppositories are also very useful for the purpose of unloading the lower bowel. When glycerin is employed, the quantity to be injected varies from one to two teaspoonfuls, according to the age of the child, and should be diluted with an equal quantity of pure water. The best instrument to use is the bulb syringe, previously recommended (page 256).

For the prevention of further constipation the diet must be regulated according to the rules given in Chapter IX (Dietary), and besides regulating the food and hours for meals, bathing, sleep, exercise and clothing, care must be taken to establish fixed habits of defecation. In my experience very young infants can be taught to use a chamber, and if this vessel be presented each day at the same hour he soon falls into regular ways.

The training should be begun after the fourth or fifth week in the following way: every morning and evening, at a fixed hour after feeding, the nurse places a small chamber between her knees, and upon this holds the infant with its back against her chest and its body firmly supported. Then to excite expulsive efforts and suggest the object of the position, a soap-stick is inserted a short distance within the rectum. Soon, however, the local irritation becomes unnecessary, the position alone being sufficient to quickly ensure an evacuation. Should faulty habits be established or constipation exist, resort to injections and abdominal massage at the same hour each day. 20

After the third year the best period of the day for the bowel to be moved is immediately after breakfast, and no call of duty or pleasure should be allowed to interfere. When constipation is to be overcome natural efforts must be made then. These efforts may at first be ineffectual, but much can be accomplished by perseverance in a daily, sustained effort, for about ten minutes. When this plan fails, use injections or other methods of relief, taking care to keep to a certain hour, that the formation of a habit may be encouraged.

Thorough rubbing of the abdomen is often successful in inducing a movement of the bowels. Gentle pressure should be made with the palm of a well-warmed hand, and the movement directed, first, from the brim of the pelvis on the right side, upward to the rib margin, then across from the right to the left, and finally downward on the left side from the margin of the ribs to the brim of the pelvis again. Such manipulation excites peristaltic action, and encourages the passage of the intestinal contents along the large bowel toward the anus. Ten minutes is quite long enough to continue the rubbing. The manipulation may be rendered more effective by using warm sweet oil as an inunction.

With children of six years and upward, daily cold spongings of the body are very beneficial, followed by frictions with a coarse towel until the surface is red.

Manna, phosphate of sodium, and gluten or soap suppositories are among the medicines that may be safely used in the nursery.

Manna, which imparts a sweet taste, may be dissolved in the food, and given from the bottle as often as required; a piece as big as a pea, once, twice, or three times a day, will be sufficient for an infant of six months.

Phosphate of sodium - an admirable laxative - can also be administered with the food; five or ten grains, three times daily, is the proper dose at the same age.

Soap suppositories must vary in strength with the age. At two months one grain of castile soap to ten grains of cocoa butter is the proper proportion; at one year the quantity of soap may be increased to five grains in each suppository, and so on. A substitute for soap suppositories may be prepared in the nursery, as follows: Cut from a bar of good castile soap a piece two inches long and half an inch thick. Scrape this into a cone, pointing one end like a sharpened pencil, but with a blunter point and more gradual slope; make it quite smooth by rubbing the surface with a wet rag (Fig. 26). When the soap stick is used anoint the pointed end with vaseline and gently insert it into the rectum and hold it there until the action begins. It is not desirable to leave any fragments of soap in the rectum. Glycerin suppositories are very efficient, but are too irritating for continuous use.

Fig. 26. - Soap Stick.