Incontinence of urine, or enuresis, as it is called, is a much more familiar symptom in young children than retention. Involuntary passage of the water may occur in the night or in the day ; and sometimes the child is unable to control his bladder either by day or by night. This distressing infirmity is far from uncommon. It may date from birth, or may be ac quired later. When acquired, its first occurrence has been attributed to fright ; but it is a popular impression that all nervous derangements are excited by some shock to the nervous system, and too much importance must not be attached to this explanation. In cases where it is not due to manifest weakness of mind or pure laziness of body, and where no disor dered condition is present to which the incontinence can be attributed, we may sometimes, by careful examination, detect some external source of irri tation which requires removal. Thus, the urine may be habitually too acid, and deposit crystals of uric acid ; there may be phimosis, allowing of accumulation of irritating secretion beneath the prepuce ; the urethral orifice may be narrowed externally ; the prepuce may be wholly or in part adherent to the glans ; or again, great irritation may be excited in the neighbourhood by thread-worms in the rectum. In a sensitive child irri tation at some distance from the bladder may act as the exciting cause. Thus, enuresis may be the consequence of chronic disease of the hip-joint, and may cease when, by rest and proper mechanical appliances, the irrita tion of the joint has been subdued. Sometimes the most careful investi gation fails to discover any such exciting cause. The incompetence is then attributed to general irritability of the nervous system, or to " spinal irritation." The mechanism of the phenomenon is well understood. Owing to causes which may or may not be capable of explanation, there is excessive irritability of the muscular fibres of the bladder. Under normal condi tions the bladder is closed by the contraction of the sphincter vesicw, whose office it is to resist the action of the fibres forming the muscular coat. If necessary, the involuntary contraction of the sphincter can be re inforced by the exercise of the will. In the more common form of incon tinence, where the involuntary passage of urine takes place at night only, the irritability of the muscular coat is exaggerated, and the resistance of the sphincter is relatively deficient. There is no atony of the sphincter, but on account of the increased pressure against which it has to contend it requires to be strengthened by voluntary agency. During sleep the agency of the will is removed, and the sphincter can no longer effectually resist the action of the irritable muscular fibres, so that the contents of the bladder are discharged. In cases where, in addition to the abnormal excitability of the muscular coat there is a certain degree of atony of the sphincter, the patient has little control over his bladder even during the daytime. Alicturition is frequent, and when the desire to pass water manifests itself, it can hardly be resisted even for a few seconds.
This derangement has been classed amongst the neuroses, with epi lepsy, chorea, and other similar affections. According to Trousseau, it is often found in families prone to epilepsy, and may thus be a hereditary failing. It cannot, however, be always attributed to a faulty condition of the nervous system. In many instances it appears rather to be due to the active reflex sensibility which is normal to the healthy child. These are the cases in which the enuresis is manifestly the consequence of some ex ternal source of irritation, and ceases when this is removed. We know how promptly, in health, the nervous system of a child responds to reflex stimuli, and we constantly have occasion to observe the perturbation into which the whole system is thrown by the action of some external irritant. No doubt the class of cases in which the power of controlling the bladder returns " of itself," more or less suddenly, are cases of this kind. As the child grows older, the extreme sensitiveness of his nervous system to ex ternal impressions becomes dulled. The only variety of enuresis which can be classed justly amongst the true nervous affections is that in which the incontinence is hereditary, or occurs in families subject to epilepsy or other form of neurotic disease,' or is apparently a consequence of nervous instability without any external cause being discovered to which the faulty action can be attributed.
Enuresis, when acquired after infancy, is generally observed first be tween the third and fourth years. It is seen as often amongst the strong
and robust children as amongst the thin and delicate ; but is, perhaps, more common in boys than in girls. The more obstinate forms of this in firmity are, however, more common in the female sex, probably because in them the complaint is less often the consequence of external irritation. In ordinary cases the accident occurs only at night, and even then not every night. Often for a week or more the bed remains dry. Then it is wetted regularly for several nights in succession, and sometimes the acci dent occurs on the same night several times. It is usually during the early hours, or later towards daybreak, that the child's bladder seems to be least under control ; and it is at these times that the incontinence is usually manifested. After continuing for a variable time the infirmity may disappear without treatment. The periods of second dentition and of puberty are popularly supposed to be sometimes marked by this favoura ble change.
In the treatment of enuresis our first care should be to search for any source of external irritation. If this can be found, its removal forms the first step to a cure, and indeed the case may require no further treatment. Thus, the removal of an elongated prepuce ; the separation of adhesions between the prepuce and the glans ; the expulsions of thread-worms, or suitable medicines by which too great acidity of urine has been remedied— all of these measures have been followed by immediate relief from this distressing complaint. Sometimes, however, such measures have to be supplemented by others, directed to lessen the abnormal irritability of the muscular coat of the bladder. In all such cases care should be taken that the child drinks little towards evening, and empties his bladder com pletely before he goes to bed. Moreover, if the incontinence occur in the early hours of the night, the nurse should be directed to take up the child and see that his bladder is properly relieved before herself retiring to rest.
Of medicines which diminish irritability, belladonna takes the first place ; but it is important to be aware that this remedy, to be effectual, must be given in full doses. Children have a very remarkable tolerance for belladonna, and will often take it in surprising quantities before any of the physiological effects of the drug can be produced. In obstinate cases of enuresis the medicine should be pushed so as to produce dilata tion of the pupils with slight dryness of the throat. In children of four or five years of age it is best to begin with twenty-five or thirty drops of the tincture of belladonna given three times in the day, and to increase the dose by five drops every second or third day, of course watching the effect. Ergot is another remedy which is often very successful. For a child of the same age twenty drops of the liquid extract may be given several times in the day. Bromide of potassium, benzoic acid (dose, five 'to ten grains), and benzoate of ammonia, digitalis, borax, cantharides, camphor, and chloral, have all been recommended as specifics in this com plaint. Sometimes a combination of several drugs seems to be more effectual than one given alone. I have lately cured a little girl, aged four years, who had resisted all other treatment, with the following draught given three times in the day :— When the incontinence continues in the day as well as at night, strych. nia should be combined with the sedative so as to give tone to the feeble sphincter. In these cases, too, cauterization of the neck of the bladder with a strong solution of nitrate of silver (Dj.- 3 j. to the ounce of water), has been found successful.
Besides drugs, other measures have been employed in obstinate cases. Thus, abstinence from animal food, including meat-broths, has been found to succeed in cases where drugs and other treatment had failed. In some country places in England a popular remedy consists in wrapping the feet of the patient at night in cloths wrung out of cold water. I have never used this remedy, but it is said to be an effectual one.
Electricity has been lately employed with advantage in these cases. One electrode in the shape of a spinal disk, connected with the positive pole of the battery, is applied to the lumbar region of the spine. A second electrode is placed above the pubes or in the perineum. A weak current is then passed for several minutes once a day. It is said that under this treatment immediate improvement is noticed, and that a complete cure follows within a fortnight.