INCONTINENCE OF URINE, AND ENURESIS.
Enlargement of the prostate is the commonest cause of urinary in continence in elderly subjects, and must be dealt with by radical surgical measures. The physician must always be on his guard against mistaking the dribbling overflow from a distended bladder for incontinence, a con dition which is very liable to arise during the course of prolonged fevers and other affections where neglect of catheterisation will tend towards a fatal result; when any doubt exists the catheter should invariably be used. Incontinence due to vesico-vaginal fistula, to the presence of prostatic or urethral concretions, or to structural bladder or urethral diseases or deformities must be dealt with surgically.
The neurosis known as nocturnal incontinence or enuresis is common in male and female children as the result of the survival of the purely reflex nature of the micturating act in the infant. There is usually nothing abnormal during the waking hours in the functions of the bladder in these cases, and there is no dribbling away of the urine at night, which is passed in a full stream during sleep.
The first step in the treatment should be the removal of any cause which tends to keep up peripheral stimulation or irritability, when any such is discoverable; it must not be forgotten that the causal agent may be located at a long distance from the bladder, as the presence of adenoids has been frequently demonstrated to be an effective factor in enuresis, though there may not be increase in the frequency of micturitiun during the waking hours.
Of the sources of stimuli arising within the genitourinary tract itself the most frequent are pinhole opening in a narrow foreskin. a very long or adherent prepuce, or a bladder calculus, thum_h the latter cause will probably also lead to vesical disturbance during the waking hours, and the same remark holds true for hyper-acidity, hyper-alkalinity, and Bacillus coli in the urine, all of which should be met by appropriate remedies in every instance where the urine is abnormal. The presence of threadworms should be sought for, as these migrate from the anus at night and may set up smart vulvar irritation and anal pruritus; obstinate constipation acts in the same manner.
Often, however, no obvious source of peripheral irritation can be detected. Before resorting to drug treatment the physician should supervise the arrangements of the patient's meals, sleeping hours, &c. The diet should be plain and unstimulating, late meals and especially fluids before bed-time being forbidden. A careful nurse or mother soon finds out what articles of food or what beverages are followed by any aggravation of the symptoms, and these can be avoided. As a rule a strung animal food dietary is objectionable, but some children are worse upon a pure farinaceous diet, with slops. The bedclothing should not be too heavy, and a hard mattress is preferable to feathers. The child should be taught to lie upon either side, and sleeping upon the back may be prevented by fastening an empty cotton-reel or bobbin or spool by means of a tape round the chest. This will awaken the patient when he turns over upon his back during the night, and feels the hard substance pressing against his spine. It is certainly the case that some children will not suffer from nocturnal enuresis unless they turn over on their back in bed.
The great secret of the successful treatment of this condition lies in careful and conscientious nursing. The writer speaks from the experience of several hundred cases treated during the last 4o years in a large in dustrial school where the complaint was constantly met with in a con siderable number of the younger girls residing in the institution. After the child has emptied the bladder he should be made to go asleep upon his side, and he must be lifted out of bed within a couple of hours and made to pass urine again, the operation being repeated in 3 or 4 hours and again before the usual time of getting up. A sensible and reliable nurse soon learns the peculiarities of each patient, and discovers the hours and number of times when such awakening is necessary as the intervals arc gradually lengthened. The great majority of cases will respond to this plan of treatment alone without drugs, though in every case these may be judiciously employed to shorten the duration of the period of nursing.