Gut, 1962, 3, 85

The treatment of constipationin mental hospitals

L. R. C. HAWARD AND H. E. HUGHES-ROBERTS

From Graylingwell Hospital, Chichester

SYNOPSIS This study investigates the incidence of constipation in two representative mentalinstitutions, and the effect, in one of the hospitals, restricting the use of laxatives to only one

drug, namely, standardized senna (Senokot). The remarkable potentiality of Senokot for long-termre-educative programmes is reflected in the reduction from 44% of 210 patients receiving variouslaxatives regularly at the'start of the trial to 8% after three months' treatment. The special studiesshowed that chronic psychotics could be freed from enemas and a substantial number (17 out of 24)cured of constipation; 31 patients on insulin therapy required maintenance doses during treatmentbut all were subsequently cured; of 25 patients with various neurological lesions, 21 were freed oflaxative treatment with four only remaining on sub-laxative doses.

There exists a two-way psychosomatic relationshipwhereby brain and bowel function influence eachother. Alvarez (1948), for example, has shown thatnervous tension particularly affects the bowelmuscles; conversely, Nobbs (1960) has found that aloaded bowel can cause mental confusion in theelderly and that the correction of constipationrestores the mental equilibrium. In examining theproblems of bowel regularity in a mental hospital weare, therefore, studying a pertinent and not un-important factor in the patient's psychiatric con-dition.The investigation to be described concerns the

extent of the problem of constipation in a repre-sentative sample of psychiatric patients, the methodsof treatment used in certain mental hospitals, andcontrolled trials of a new preparation with selectedpatients in special diagnostic categories. In the past,constipation has generally been defined on a tem-poral basis. For example, Hurst (1937) states thatconstipation is a condition in which the residue offood ingested during one day is not excreted withinthe next 48 hours. Such a conception does not takeinto consideration those cases with a bowel rhythmgiving normal motions every third or fourth day,and it is more physiological to use the definition ofCecil and Loeb (1959) who regard constipation asthe passage of unduly hard and dry faecal matterregardless of the time factor or the number ofmovements. In the present study, which relied inpart on the objective assessment of constipation by a

large number of psychiatrists each possessing hisown idea of what constitutes the disorder, it wasfound necessary to employ the basis of the actualprescription of an aperient.

INCIDENCE

Forms were circulated to the pharmacy departmentsof mental hospitals in England asking for details ofthe use of laxatives. From the replies it was clearthat ward issues ranged from one predominant or afew well-chosen aperients to the whole gamut oflaxatives. In some hospitals laxatives were prescribedonly by the medical officers; in others they were dis-pensed by, and at the discretion of, sisters and chargenurses. Table I gives the number of patients treatedfor constipation during one week in two hospitals,

TABLE IPATIENTS TREATED FOR CONSTIPATION IN ONE WEEK

IN TWO REPRESENTATIVE HOSPITALS

Hospital

A B

Number of beds

Number of patients receiving laxativesMale in-patientsFemale in-patientsTotal

Percentage of bedstate

85

2,219

664833

1,497

997

66223289

70 30

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L. R. C. Haward and H. E. Hughes-Roberts

chosen to illustrate extreme attitudestipation. Hospital A provides aperiand also 48 hours after the last bohospital B dissuades patients from tand allows them only when an appr(elapsed since defaecation.

In Table lI the types of laxative entwo hospitals are shown with the

TABLE IILAXATIVE TREATMENT FOR ONE MONTH

Treatmnent Unit

EnemasLiquid paraffinMist. aperientMist. albaMist. phenolphthaleinSaline saltsCascara: Elixir

TabletsSenna (Senokot)Colocynth

Oz.Oz.Oz.Oz.DosesOz.TabletsTabletsTablets

TABLE IIIANALYSIS OF INCIDENCE OF CONS]

CAUSES IN MENTAL PATIE

A Organic and pathological(i) Central nervous system pathology(ii) Hypothyroidism(iii) Obesity(iv) Cachexia(v) Idiopathic megacolon

B Pharmacological(i) Insulin treatment(ii) Psychotropic treatment

C ImmobileChronic mental patients

D Psychological(a) Primary predisposing factors'

(i) Autonomic imbalance(ii) Personality traits(iii) Other factors

(b) Secondary to mental disorders2(i) Schizophrenic(ii) Depressive(iii) Psychoneurotic

(c) With psychogenic dietary problems'(i) Premorbid(ii) Acute schizophrenia(iii) Protracted depression

Total cases

ts towards con- scribed. To make the figures comparable, these haveients on request been given as treatments per month per 1,000 beds.wel movement; The incidence of constipation was then analysedtaking aperients in terms of cause in all patients in hospital Aeciable time has receiving aperients during the study week (column

2 of Table I) and the analysis is shown in Table III.nployed in these It will be seen that less than 4% of the samplequantities pre- suffered with constipation apparently unrelated to

their mental state. The significance of the psycho-logical factors existing in other cases will be discussed

PER 1,000 BEDS later.It will be seen from Table I that the in-patient

Hospital figures show a sex difference in which significantly

A B more females than males received aperients, whereasin a pilot study conducted at the psychiatric out-

80 128 patient clinic, it was found that the sex difference8,000 160 was not significant. Unless the in-patient sex

0 150 difference is a sampling artefact the sex equality in80 06 0 the out-patients suggests that this phenomenon is

320 0 related to prescribing aperients rather than to0 3210 319 taking aperients, and this may indicate an interesting20 0 facet of attitudinal differences between male and

female nurses. Of those out-patients who reportedbeing constipated, 60% complained of habitual

lIPATION BY constipation, while the overall incidence of con-NTS stipation amongst out-patients (Table IV) is similar

to that found by other investigators, e.g., Wager31 and Melosh (1958).

841

31138

45 TABLE IVINCIDENCE OF LAXATIVE TAKING IN

PSYCHIATRIC OUT-PATIENTS

169 Out-patients

Males Females100 100499 Sample number

83219

477117103

1774

'Constipation arising, before the onset of current mental illness, frompsychophysiological factors which characterize the premorbid per-sonality and predispose the organism towards mental disorder."Constipation arising after onset of a mental disorder as a result ofthe behavioural symptoms, e.g., psychomotor retardation in melan-cholia.'In this group the mental disorder has produced abnormal attitudestowards food which eventually lead to chronic constipation, e.g., theschizophrenic possessing delusional ideas concerning the symbolicsignificance of the ingestion of food, believing it to induce pregnancy.

Number taking aperients during study weekNumber taking aperients regularly

47 3927 21

An analysis by age and duration, however, pro-duced figures different from those previouslyreported. Table V illustrates the shift from the

756 middle-aged group to the extreme, and probablyreflects the higher medication with constipatingpsychotropic drugs amongst the younger patients,together with the large number of elderly and rela-

28 tively immobile patients.1,497

TABLE VCOMPARISON OF INCIDENCE OF CONSTIPATION WITH

AGE IN MENTAL AND NON-MENTAL PATIENTS

Under 25 25 to 50 Over 50( %) ( %) Years ( %)

Psychiatric (present study)Medical/surgical (Lamphierand Ehrlich, 1957)

27 26 47

14 53 33

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The treatment of constipation in mental hospitals

SELECTION OF APERIENT

It is clear that the efficient treatment of constipationrequires the limitation of laxatives to preferably oneaperient of general efficacy; the laxative must beinexpensive, easy to administer, and physiologicalin its action, so that a rational treatment of bowelre-education (in contrast to the symptomatic andtemporary relief by purging) can be initiated. Of allthe laxatives available, the claims of standardizedsenna for general use appeared outstanding.Bulk laxatives containing psyllium and other

hydrophylic colloids are contraindicated in con-stipated subjects with a distended atonic bowel andelsewhere they are of uncertain value (Francillon,1952). Salines act by increasing the fluid contentwithin the lumen of the bowel, with resultantstimulation of the small as well as the large intestineand are thus unphysiological for regular use.

Castor oil, vegetable laxative tablets N.F., whichcontain jalap, colocynth, and podophyllin, areirritant purgatives affecting both small and largeintestine. Their excessive use leads to serious de-pletion of sodium and potassium, and they have noplace in modern medicine (Coghill, McAllen, andEdwards, 1959; Burgess, 1958).

Liquid paraffin and its emulsions continue to bewidely used but this would seem to be due to habit,albeit a bad one. The evidence condemning their useis now overwhelming. Becker (1952) quotes 52references describing its deleterious effect.The more recently introduced 'contact' laxatives,

such as the bisacodyl substance (marketed 'ethically'as Dulcolax and 'publicly' as Tempo) are relativelyexpensive and are contraindicated when alkalis arein use. The suppositories have been used with successalthough little is known of their pharmacology.

These are exceptionally palatable and can be ofmuch value when it is necessary to conceal from thepsychiatric patient that a drug is being given. Bothgranules and tablets are standardized in terms ofsennosides A and B.Douthwaite and Goulding (1957) confirmed, by

feeding high doses of Senokot to mice, that therewas no evidence, either macroscopic or microscopic,of any irritant, i.e., inflammatory change in the gut,while Fairbairn (1958) showed that mice given largedoses over a period of nine months continued tothrive with no sign of harmful effect. There appearsto be no danger from the ingestion of large doses,always a risk with psychiatric patients, for Hawkins(1958) reports the case of a 7-year-old boy who con-sumed 2 oz. (60 g.) of the granules without anyevidence of systemic toxicity.Animal experiments have shown that the senna

glycosides are first absorbed from the small intestineinto the systemic circulation and re-excreted into thecolon. Here they are broken down by enzyme actionor intestinal flora to release the active principle,which presumably stimulates sensory receptors inthe intestinal mucosa (Straub and Triendl, 1937;Okada, 1940), and through Meissner's andAuerbach's plexuses the intrinsic peristaltic reflex isproduced. This physiological stimulation of intes-tinal peristalsis substantiates the claim that sennaproduces a good reproduction of normal peristalsis.Some analogy to the sensitizing action of 5-hydro-xytryptamine would seem to be apparent.

Pharmacological studies (e.g., Lenz, 1924;LeBoeuf, 1949; Valette, 1949) and clinical reports(Braid, 1954; White and Dennison, 1958; Campbell-Mackie, 1959; Katz, 1960; Dubow, 1960; Coekinand Gairdner, 1960, and others) indicate that theessential action of Senokot is to increase the tone ofthe colonic musculature.

THE STIMULANT LAXATIVES

These include phenolphthalein and the anthracenedrugs senna, rhubarb, aloes and cascara.

Phenolphthalein, a pure substance, with a

chemical structure having some similarity to that ofthe anthracene glycosides, is, generally speaking, asafe drug. It can, however, very occasionally giverise to allergic reactions such as skin rash.The anthracene group of laxatives are physio-

logically attractive, since their stimulant action ismostly confined to the large bowel. However, onlyin the case of senna is a fully active, standardizedpreparation available, namely, Senokot.' There are

two forms: granules and tablets. The granules are

prepared with a mixture of malt, cocoa, and sugar.

1Westminster Laboratories Ltd.

WARD TRIALS

Having decided upon the most suitable aperient, theaim of the second part of the investigation was tointroduce it into ward routines in order to (1) judgethe ability of the nursing staff, under medicaldirection, to deal satisfactorily with problems ofconstipation with only the selected aperient, and(2) examine its efficacy in the special problemspeculiar to a mental hospital population.The wards selected for the trial had all existing

stocks of aperients withdrawn and Senokot in bothgranule and tablet form issued. There were 210patients in this part of the study: the average dosagewas one teaspoonful at night followed by twoteaspoonfuls the following night if no evacuation had

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L. R. C. Haward and H. E. Hughes-Roberts

taken place. The granules were mixed with the bed-time milk to produce a pleasant chocolate drink andthe patients were not informed that this was alaxative unless they asked. The purpose was toeliminate the psychological effect of drug taking sothat the morning evacuation might become associatedwith a habit time rather than with the taking of alaxative. In the event, a number of patients who hadrelied on laxatives for many years required higherand more frequent doses of hidden Senokot beforeit was effective, and these patients were, therefore,given the drug in tablet form to begin with, this beingreplaced gradually with the granules until the patientfound himself regular with the aid of the unidentifiedaperient. Once this had been achieved it was thenpossible to establish regularity on diminishing dosesin a manner parallel with that of the other patients.

RESULTS

At the beginning of the study 44% were receivingaperients in any one week. By the end of the firstmonth 31 % had received aperients during the pre-ceding week, and by the end of the second monththe figure had been further reduced to 11 %. At theend of the third month the incidence was 20% butthis included new patients recently transferred tothose wards and only 8% of the original number wereon a maintenance dose which, in most cases, was asub-laxative one sufficient to maintain regular bowelaction. These figures are similar to the findings ofother investigators using Senokot. Flintan andWeeden (1953) found a 7% failure rate with theirsample, Lamphier and Ehrlich (1957) a 5% failurerate, and Wager and Melosh (1958) a 6% failure rate.Those patients who suffered from chronic constipa-tion and had a lifelong dependency upon regularmedication with aperients, complained of abdominalcramps and transitory diarrhoea when the dosagewas raised to three or four teaspoonfuls. Withexperience, the nurses found that by dividing thelarger doses twice daily both griping and loose stoolscould be eliminated.

REPLACEMENT OF ENEMAS

Concurrently with the programme of ward studies,several individual studies were conducted on groupsof patients who presented as special problems of con-stipation. The first group comprised 24 chronicpsychotics who had been on twice-weekly soapenemas for many years. In the first month of the trialthe regimen was changed to one enema weekly plusSenokot tablets in lieu of the other enema. Dosagewas adjusted to suit individual requirements and atthe end of four weeks the remaining enema was dis-

pensed with in favour of Senokot. For these difficultcases tablets were used in preference to the granulesas the ward studies had shown that patients con-ditioned to enemas required a more tangible alter-native than that provided by the granules. Thispsychologically important fact was established by apaired trial in the form of a pilot study which showedthat patients receiving Senokot in place of an enemarequired a higher dose in the form of granules thanthey did of tablets. In weaning patients from enemas,the four-week period was found to be extremely use-ful in enabling doses to be adjusted conscientiously:the weekly enema which had been retained for thisperiod provided some support for the nursing staffand, at the same time, avoided the use of excessivelylarge doses. During the second and subsequentmonths, enemas were discontinued altogether, andthe dosage was gradually reduced in the hope that thegroup would be completely free of aperients. By theend of three months no fewer than 17 of the original24 patients were regular and free of aperients, whileseven still required a regular maintenance dose.Some of the 17 patients who achieved bowelregularity were given a sub-laxative dose on request.

INSULIN PATIENTS

The second individual study involved patients receiv-ing psychiatric insulin treatment, 31 of whom com-plained of constipation. Twenty of these wereselected for a long-term trial, having only recentlybegun this treatment, while the remaining 11 wereinvestigated for as long as they were in the insulinunit. While this group required only minimal dosesof standardized senna administered every four days,it was found impossible to dispense with the aperientaltogether during the period in which insulin therapywas in progress, although once treatment had beencompleted it was found that bowel regularity con-tinued without the need for further administrationof the aperient. It had been suggested that freedomfrom constipation would not be obtained untiltreatment had been completed because of the inter-ference with normal physiology involved in insulinmetabolism, and this small-scale investigation sup-ported the indication for concomitant regular dosesof standardized senna during insulin therapy.

PATIENTS SUFFERING FROM ORGANIC DISEASE

Twenty-five patients suffering from various chronicorganic conditions were studied. Twelve were in apost-encephalitic condition, three suffered fromparaplegia, nine from general paralysis of the insane,and one from a residual intracranial pathologyoriginating in a head injury. These patients had

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The treatment of constipation in mental hospitals

atypical problems of defaecation, six being incon-tinent of faeces and the others showing transitoryphases of constipation or alternating phases of con-stipation and diarrhoea. The hypothesis was that theparticular organic condition of these patientsincluded interference with the functioning of thesupraspinal or pudendal defaecation reflex, andalthough it was felt unlikely that a normal reflexcould be established in such cases, a trial was under-taken to determine what measure of support couldbe achieved with standardized senna. Dosages variedaccording to the individual patient but in all caseswere much higher than those required in the othergroups. During the first month attempts were madeto achieve regular defaecation, and to this end doseswere given which were high enough to ensure a motionand these were determined from the trial and errorperiod of the first week. A characteristic of thisgroup was that no patient, except the post-traumaticcase, complained of griping even at three times theaverage maximum dose and this enabled the nursingstaff to give an adequate level of the aperient withconfidence. The patience and perseverance of theward staff deserve special commendation, as thefirst fortnight produced considerable incontinencein this group. This condition proved to be a necessarypreliminary to the establishment of regularity inthese patients for, until a short period of incon-tinence had been obtained, residual traces of thehabits inculcated by a protracted enema routineappeared to exist and interfered with the retrainingregimen. The period of incontinence seemed to havethe effect of destroying, temporarily at least, thechronic dependence upon enemas and provided aneurological tabula rasa, to borrow a Cartesianterm, upon which the new reflex habits engenderedby the Senokot programme could be impressed.Of this group three patients in a post-encephaliticstate and one suffering from general paralysis ofthe insane required regular maintenance doses ofSenokot although none of the group had to revertto enemas. These four were the most intellectuallydeteriorated of the group, and from inspection thereappeared to be some correlation between the timerequired to establish bowel regularity and the degreeto which the intellectual capacities had been pre-served. One characteristic of Senokot which wasinvaluable in the bowel re-education of patientssuffering from organic disease was the narrow rangeof times between administration and evacuation.Although this has been given by Herland andLowenstein (1957) as three to 12 hours (mean eighthours, standard deviation 2.2 hours) the figures foradministration at night are more consistent. Withthe psychiatric sample of 50 patients in whom thesetimes were studied accurately, the range obtained

was seven to 12 (mean 8.7 hours, standard deviation1.3 hours), although figures outside these limitswere occasionally obtained with other patients.These figures compare very favourably with thosegiven for other aperients.By giving Senokot granules in the bedtime drink,

the nursing staff were able to get the plegic patientspositioned on the W.C. soon after waking, wherethey could remain until their bowels functioned,and this could only have been conveniently organizedwith an aperient possessing a predictable time ofonset. Since this study was completed, Jarrett andExton-Smith (1960) have described a method oftreating faecal incontinence in elderly patients withneuropathology. The regimen consists of imposinga periodicity of bowel action by the alternate use,night and morning, of agents with opposite pharma-cological effects, namely Senokot and an opiate(in this case, mist. kaolin et morph.).There is littledoubt that such a regimen would have improvedconsiderably the management of the cases in theearly phase of the present study.The results of the ward studies and the three

special studies are summarized in Table VI.

TABLE VIRESULTS OF TRIALS WITH STANDARDIZED SENNA

IN PSYCHIATRIC PATIENTS

Studv

ABC (a)

(b)D

Total cases

Sample NumberSize Regular after

SenokotTreatment(DosageDiscontinued)

21024313125

321

193170

3121

262 (81-6%)

NuimberRegular withMaintenanceDoses ofSenokot

177

3104

59 (18-4%)

NumberRequiringOther FormsoJ Treatment

00000

Study A Mixed psychiatric patients possessing various problems ofconstipation, most of them on psychotropic drugs possessing con-stipating properties.

Study B A selected group of chronic psychotics with long-standingconstipation problems and receiving twice-weekly enemas.

Study C A group of patients receiving insulin coma therapy whoseconstipation was considered to be a direct consequence of the treat-ment (a) during and (b) after.

Study D A group of organic psychotics whose bowel dysfunctionwas related to neuropathology.

DISCUSSION

The constipated psychiatric patient poses a specialproblem since there are a host of mental conditionswhich produce bowel dysfunction. In the patientsstudied here, psychogenic causes included the

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90 L. R. C. Haward and H. E. Hughes-Roberts

complete spectrum of psychosomatic mechanisms,ranging from the emotional turbulence of psycho-neuroses to the psychomnotor retardation of apsychotic depression.

In mental patients what is required is the completere-education of the defaecatory reflex to such adegree that it will function regularly and indepen-dently of future psychogenic constipating processes.Therapy of this kind is based on the 'conditioning'technique first devised by Pavlov and now widelyused in medical psychology under the name of'behaviour therapy' (Eysenck, 1961). Early condition-ing of bowel function when a young infant is pot-trained long before the spinal nerves are sufficientlymyelinated to provide conscious control is of thistype.Treatment of constipation by conditioning

involves the establishment of a rhythm by firstdestroying existing associations with external con-ditioned stimuli, and reverting to the natural stimulusof a full bowel, reinforced by a temporal overlay.At the time of writing, Senokot is the only suitablepreparation for this technique. Its ready conceal-ment enables the laxative-evacuation relationshipto be broken, and its time of action has close limitswhich enable habit formation to take place withcomparative facility. Also important is its consis-tency of action, for without this, conditioning wouldbe ineffective. Its primary advantage over otheraperients must be, however, its neurophysiologicalmechanism, for by using the alimentary neuralpathways of the autonomic nervous system it strikesat the very roots of psychogenic constipation.However, in psychiatric patients where neuro-

psychological processes operate to produce bowelmalfunction, or where chemotherapy producesconstipation as a side-effect, these factors prevent thesuccessful establishment of regularity without con-tinuing medication. Even these patients, however,can be made regular with the aid of sub-laxativemaintenance doses. Dosage requires adjustment sincepsychiatric patients in particular show a wide rangeof individual differences in sensitivity.

REFERENCES

Alvarez, W. C. (1948). An Introduction to Gastro-Enterology, 4th ed.,p. 617. Hoeber, London.

Becker, G. L. (1952). The case against mineral oil. Amer. J. dig. Dis.,19, 344-348.

Braid, Frances (1954). The treatment of constipation in children.Med. Press, 231, 521-524.

Burgess, D. E. (1958). The treatment of constipation-A physiologicalapproach. Pharm. J., 181, 337-340.

Campbell-Mackie, Mary (1959). The treatmnent of bowel dysfunctionin infants and young children. Practitioner, 183, 732-736.

Cecil, R. L., and Loeb, R. F. (1959). Constipation. A Textbook ofMedicine, 10th ed., p. 829. Saunders, London.

Coekin, M., and Gairdner, D. (1960). Faecal incontinence in children.Brit. med. J., 2, 1175-1180.

Coghill, N. F., McAllen, P. M., and Edwards, F. (1959). Electrolytelosses associated with the taking of purges investigated withaid of sodium and potassium radioisotopes. Ibid., 1, 14-19.

Douthwaite, A. H., and Goulding, R. (1957). Action of senna. Ibid.,2, 1414-1415.

Dubow, E. (1960). Constipation in infants and children. Arch. Pediat.,77, 261-267.

Eysenck, J. H. (1961). Behaviour Therapy and the Neuroses.Pergamon Press, London.

Fairbairn, J. W. (1958). Action of senna. Brit. med. J., 1, 218.Flintan, P., and Weeden, G. D. (1953). Standardized senna. Lancet,

1, 497.Francillon, J. (1952). Un cas d'il6us d'origine th6rapeutique. Lyon

Chir., 47, 888-889.Hawkins, D. B. (1958). Action of senna. Brit. med. J., 1, 281.Herland, A. L., and Lowenstein, A. (1957). Physiologic rehabilitation

of the constipated colon in pregnant women. Quart. Rev. Surg.Obstet. Gynec., 14, 196-202.

Hurst, A. F. (1937). Constipation. In The British Encyclopaedia ofMedical Practice, ed. H. Rolleston, Vol. 3, pp. 376-384.Butterworth, London.

Jarrett, A. S., and Exton-Smith, A. N. (1960). Treatment of faecalincontinence. Lancet, 1, 925.

Katz, R. (1960). Evaluation of standardized senna in the treatment ofrefractory constipation. Med. Press, 243, 355-356.

Lamphier, T. A., and Ehrlich, R. (1957). Evaluation of standardizedsenna in the management of constipation. Amer. J. Gastroent.,27, 381-384.

LeBoeuf, H. (1949). Sur le Mode d'Action des Purgatifs Anathra-quinoniques. These Doct. Pharmacie, Paris.

Lenz, E. (1924). Observations a la fenetre abdominale "colique" duchat. Arch. int. Pharmacodyn., 28, 75-157.

Nobbs, K. L. G. (1960). Confusion in the elderly. Lancet, 2, 888-889.Okada, T. (1940). Ober den Mechanismus der Sennaabfuhrung.

Tohoku J. exp. Med., 38, 33-44.Straub, W., and Triendl, E. (1937). Theorie der Abfuhrwirkung der

Folia sennae und ihrer wirksamen Inhalstoffe. Arch. exp. Path.Pharmak., 185, 1-19.

Valette, G. (1949). Effet sur l'intestin isole des glucides du sCn6(sennosides A et B) et de leurs produits d'hydrolyse. C.R. Soc.Biol. (Paris), 143, 74-76.

Wager, H. P., and Melosh, W. D. (1958). Management of constipationin pregnancy. Quart. Rev. Surg. Obstet. Gynec., 15, 30-34.

White, M., and Dennison, W. M. (1958). Constipation. Surgery inInfancy and Childhood, p. 196. Livingstone, Edinburgh.

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