THE TREATMENT OF INCONTINENCE OF URINE IN CHILDREN. BY CHARLES W. TOWNSEND, M. D. Reprinted from the Boston Medical and Surgical Journal of December 22, 1892. BOSTON: DAMRELL & UPHAM, Publishers, 283 Washington Street. 1892. S. J PARKHILL 4 CO., PRINTERS BOSTON THE TREATMENT OF INCONTINENCE OF URINE IN CHILDREN.1 BY CHARLES W. TOWNSEND, M.D. From time to time articles appear in the medical journals extolling this or that form of treatment for in- continence of urine in children, and condemning other forms as useless in the experience of the writer. In fact, there is no disease where such a conflict of opinions is held as to its treatment. This would lead us to in- fer, and with reason, that the affection is decidedly difficult to cure. An understanding of the etiology of this disease is, however, essential to its successful treat- ment, as I attempted to show in a former article,2 so that we may adopt the treatment suitable to the indi- vidual case rather than use any one routine method for all. Acting on this principle, I have endeavored to treat cases in the out-patient department at the Children's Hospital and in private practice, and have collected and analyzed them, to study the results. Up to March 14, 1892, there were 94 cases entered under the diag- nosis of incontinence in the out-patient records of the Children's Hospital; many of these had come under my own supervision, for the rest I am indebted to the records of my colleague. Six more cases were added from my private records so as to make a total of 100 in all. Exactly half of these, oddly enough, were in boys, and half in girls. 1 Read before the Boston Society for Medical Improvement, No- vember 14,1892. ' Archiv. of Pediatrics, December, 1887. 2 The ages are given in this table: 2 years 2 cases. 3 " 6 " 4 " 11 " 5 " 7 " 6 " 11 " 7 " 10 " 8 " . 9 " 9 " 6 " 10 years 11 cases. 11 " 11 " 12 " 9 " 13 " 4 " 14 " 1 case. Not given 2 cases. Total. 100 Forty-seven were cases of nocturnal incontinence only; two were diurnal only; and 47 were both nocturnal and diurnal. In three there was also at times incontinence of fasces. I. Malformations of bladder or urethra. Cases. 1. Epispadias 1 2. Small meatus 2 II. Atony of sphincter vesic®. 1. General debility or ansemia ...... 17 2. Spinal disease 0 3. Acute febrile disease ....... 0 III. Reflex. 1. Increased quantity of urine. (а) Nephritis . . . (б) Diabetes .... 2. Irritant quality of urine. (a) Excess of urates and uric acid (&) Increased acidity . . 3. Vesical calculus 4. Hypersensitive state of external genitals from (a) Phimosis 11 (d) Adherent prepuce with or without retained smegma and ballanitis 22 (c) Vulvitis 1 (d) Masturbation 1 5. Anal irritation. (a) Worms . . . .6 (b) Eczema 1 (c) Rectal polypus 1 69 6. Increased irritability of the bladder from unknown causes 31 Total, 100 The attempt was made, as far as possible, in most of the cases to ascertain some probable cause of the 3 affection, and to treat or remove it; and I have arranged these in the following table under three main heads as an aid in finding the cause and treating the trouble. As will be seen, in 69 per cent, of the cases there was found some cause which might reasonably be held responsible for the trouble, and it is probable that this percentage would have been increased if all the cases could have been carefully studied. The results of treatment in these 69 cases, although often discouraging, was decidedly better than among the other cases where the treatment was more routine ; and it is undoubtedly the fact that many more would have been permanently cured if their parents had not withdrawn them from treatment too soon, being dis- couraged by former unsuccessful attempts and by the general scepticism as to the advantage to be derived from treatment in this trouble. The case of epispadias was operated on, and proved, I believe, a permanent success. Both of the cases of incontinence due to a congenitally small meatus were cured by nicking and stretching the meatus. One was an infant of sixteen months, where besides the very fre- quent micturition, there was constant priapism due to the reflex irritation. Both of these symptoms were at once relieved by simply nicking the meatus and stretch- ing with a pair of scissors. Micturition took place only three or four times daily, while before this the mother assured me that a little water was passed nearly every fifteen minutes. Of the 17 cases entered as atony from anaemia and general debility, treated with iron and strychnia in the form of nux vomica, and with general hygienic methods, in seven the result of treatment was unknown, four were not relieved, two were improved and four were cured. It is to be remembered that many hospi- tal cases give up treatment before it is hardly begun, 4 so that these results are not a fair test. Rhus aromatica has been reported of much use in these atonic cases. I have not yet used it. I am inclined to think that some of this set of cases were due to reHex causes which be- came inoperative on strengthening the general condi- tion. On looking over the list I have given of reflex causes, it is evident that many of them occur in cases when there is no incontinence of urine; but that un- der certain circumstance, they may be the exciting cause of incontinence is evident theoretically, and is proved practically by the cure of cases on the removal of the reHex cause. Complete cure in this annoy- ing disorder is so satisfactory to all concerned, that we should certainly leave no stone unturned in our search for and removal of the reHex source (if happily there is one) of the incontinence. Five cases are recorded as due to excess of urates and uric-acid or to increased acidity of the urine. Two were relieved, and two cured by treatment with alkalies (Carlsbad salts in two cases), and also by treatment in two cases of the existing dyspepsia. It is natural to suppose that an over-acid urine, especially if it contains uric-acid crystals, might in a child, where the nervous tension is so great-and it is especially so among the lithmmic- send such strong impulses to the reflex centre for micturition in the lumbar spinal cord that they could not be overcome by impulses from the brain. Incontinence would be the result. This would occur most commonly during sleep when the centre for voli- tion is least active, but might, of course, if the irrita- tion were sufficiently strong, occur during the waking hours. I am inclined to think that there were many more cases on my list where the source of the trouble was an over-acid urine due to a lithaemic condition. For 5 purposes of analysis it is important to obtain several specimens of the urine passed at home, and not the specimen passed at the hospital clinic or office. In this case the child may have waited some time in a more or less nervous state of mind, and the urine is thereby rendered copious and watery with a low specific gravity,-thus reversing the characteristic over-acid concentrated urine, which throws down on standing a deposit of urates with its red-pepper grains of uric-acid. This variability in the character of the urine is com- mon in litbaemic children, owing to the accompanying neurotic condition. The use of a vessel at home in place of the water-closet, with the report of the mother's observation on the same, is of great value. As Fothergill has so graphically shown in the "Cyclopaedia of Children's Diseases," lithuria is of very frequent occurrence in children. He says of lithiemic children (Vol. II, p. 301): "Their bladder is a source of much trouble to them and its calls are often peremptory "; and on page 304, " wetting the bed at night has close relations with uric acid, and in all cases of nocturnal incontinence the urine should be examined. In my experience wetting the bed occurs mainly in two classes of children, - in very bright, vivacious neurotic little girls, and in comparatively dull and backward children of low nervous organiza- tion. In either case the uric acid present plays a part." Phimosis as a cause of incontinence has always been a fruitful source of argument. Some maintain that circumcision is a certain cure, others that this opera- tion is valueless. On my list are eleven cases of ex- treme phimosis, seven of which were circumcised. In 22 others, there existed a more or less elongated fore- skin with adhesions which prevented complete retrac- tion. Of the circumcised, four were not relieved, one was much relieved and one cured,- a pretty poor show- 6 ing. The 22 with adhesions were all cases where the foreskin could be retracted on breaking up the adhe- sions, and where it, therefore, did not seem to be neces- sary to advise circumcision. Five of these cases were not relieved, in six the result was unknown as the pa- tients could not be found, three were relieved tempora- rily, one was much relieved but not cured, and six were entirely cured. The operation consisted in drawing back the foreskin and gradually breaking the adhesions that bind it to the glans around the corona. Sometimes this occupied two or three sittings, although it was gener- ally possible to break up all the adhesions at one time. Cocaine relieves the pain to some extent. In some cases ether should be used, although with care one is generally able to do without it and cause but little pain. The glans, especially behind the corona, should then be smeared with vaseline to prevent the raw sur- faces from reuniting, and the parents instructed to have the foreskin retracted and washed and anointed with vaseline twice a day for a few days, after that once a day only at the morning bath. If this precaution is not taken, it may be necessary to subsequently break up some new-formed adhesions. In several cases this was done, the second operation completing the cure. Sometimes a mass of irritating smegma is found be- hind the adhesions which must be thoroughly removed. It is surprising how often a foreskin which seems so tight as to require circumcision will, with a little patience, admit of retraction, and it has seemed to me that circumcision could generally be dispensed with, provided the foreskin could be retracted so that adhe- sions could be broken and all irritating smegma re- moved. In other words, a long foreskin without adhe- sions or retained smegma is not a source of reHex irritation while a short foreskin with these may be. This was well illustrated in one case where a child was 7 brought to the hospital for incontinence, for the cure of which circumcision had already been done without any success. On examining the penis which had been properly circumcised, a collection of smegma and dirt, evidently very irritating, was found in the groove be- hind the glans, and removed, a soothing ointment being applied. Improvement was marked at once; and at the end of a week the cure was completed, and remained so. I do not wish to be understood to think that adhe- sions between the foreskin and glans always cause in- continence, or that the trouble can always be cured by their removal. On the contrary, it is almost the rule to find adhesions in young children. Dr. Roswell Park" found them in eighty per cent, of all cases, in greater or less degree in young children. It seems reasonable, however, to suppose that in some cases with an easily disturbed bladder, that the reflex irritation of adhesions, especially with retained smegma, may be all that is needed to start involuntary micturition, and that the removal of these conditions may be all that is needed to cure it. The success sometimes attending this simple operation certainly makes it advisable to perform it where we can find no other cause of the trouble. Its failure in many cases simply shows that we have not found the whole source of the trouble, or as is often the case, the nervous habit has be- come so fixed that it cannot be stopped, even on removal of the original exciting cause. If we cannot retract the foreskin so as to break up the adhesions, I believe it is best to circumcise and not to promise too much as to the result, for it is unfortu- nately the case that circumcision will not always cure, as is illustrated by the failures on my list. I have seen the trouble in the circumcised Jew. 9 Chicago Medical Journal and Examiner! 1880, p. 561. 8 A large number of cases of vulvo-vaginitis in little girls are seen at the hospital, but curiously enough I can find only one case of incontinence among them. That came on in a previously healthy and continent child shortly after the onset of an acute attack of vulvo- vaginitis probably of infectious origin. An adherent clitoris has been said to cause inconti- nence. This I have not observed. Reflex irritation from pin worms, or eczema about the anus, may certainly cause incontinence, and should be removed before any other treatment is attempted. The rectal polypus was removed from the child on my list, with immediate cure of the incontinence of urine. By all means find, if it is possible, a reflex cause of this troublesome disease and remove it, and the results will be the best, for the direct medical treatment is often most discouraging. I am convinced that the very favorable reports of the use of various methods of treatment are often due to the fact that sufficient time has not been allowed to elapse in the treatment of cases. Many of the families who come to the Children's Hos- pital are followed up for years and I wrote to as many of the patients as I could find who had been lost sight of. In this way it was found that many who were entered in the record as improving or cured, subse- quently relapsed. Private cases that can be followed up more carefully are not so apt to relapse. Belladonna is the drug par excellence that is used in a routine way for enuresis. In fact, it is generally prescribed without looking for any exciting cause to remove. In my set of cases it was prescribed in 44 cases, generally after a search for a probable cause or lack of success following its removal. I think a more careful examination, especially of the urine, might have reduced the number in which belladonna was used. 9 The results of its use are not very encouraging, espe- cially if one is careful, as I have tried to be, to follow up the subsequent history of the case. Many of my replies showed that the trouble supposed to be cured soon returned as bad as ever. Still there are some signal successes. The corrected results are as follows : Of the 44 treated with belladonna, in 12 the result is unknown; 12 were not relieved; three were cured for a short time, but later relapsed; 12 were more or less relieved ; and five were entirely cured. Although in large doses belladonna will generally partially or entirely relieve for a short time, still in some cases there is no improvement, even if the drug be pushed to poisonous doses. For example, in a boy of five the dose was gradually increased from five to thirty drops of the tincture when physiological symp- toms came on and the treatment continued in large doses for several months without success. This I have mentioned to show that persistence and large doses of belladonna does not invariably cure as is claimed by some and is, it seems to me, an objectionable practice and detrimental to the health of the child. There are enough successes on the list, however, to warrant its trial, provided we have exhausted other means. It can be given in the form of the tincture, or as atropia, one grain to the ounce, giving one-half to one drop for each year of the child's age. For nocturnal incon- tinence it is best given two hours before bedtime and again at bedtime if the pupils are not dilated. In this way the full effect can be safely obtained. The other drugs used, not before mentioned, were ergot and bromide of potash, which were both unsuccessful; and iodide of potash, which seemed to have a good effect in one case. In six cases faradism was used: without success in two ; three were relieved; one was cured. Raising the foot of the bed to prevent the urine press- 10 ing on the neck of the bladder certainly has a tempor- ary good effect in many cases, but no cures were obtained. Daily dilatation of the bladder with warm water in chronic cases where this viscus has become contracted and thickened, is a form of treatment which seems rational, and good results are reported. In conclusion I would say, study each case of incon- tinence of urine, and find and remove the cause if pos- sible. In this way the results will be much better than by any routine treatment. Two Volumes yearly, beginning with the first Nos. in January and July. But Subscriptions may begin at any time. 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