DYSURIA, ENURESIS, AND RETENTION OF URINE.
Any dissertation on circumcision and its many uses, either prophylactic
or curative, would be incomplete without a reference to enuresis;
another reason for making a somewhat full reference to the subject would
be the undecided position that this morbid condition seems to occupy in
medical literature, as well as the meagre and unsatisfactory treatment
it has received by the majority of those who have mentioned it. It is
anomalous, to say the least, to find, in general or special literature,
enuresis mentioned as a diseased condition peculiar from babyhood to
puberty; to find it fully described and to have it stated that it is a
widely-prevalent distemper, affecting both sexes alike; to know that it
is an annoying, intractable, persistent condition, wearing to the child
in every sense, subjecting it to a demoralizing mortification as well as
to unmerited scoldings, humiliations, and punishments, and that its
habit, in badly-ventilated quarters, will breed other diseases,[107] as
well as that its continued action tends to the development of onanism,
with its long and widely-ramifying trains of physical and social ills;
and to find works especially devoted to children's diseases silent on
the subject. Knowing all these things, and also that Ultzmann,
Lallemand, and others who have treated this affection, mention it as a
children's disease, it is unaccountable to reason out why most of our
text-books and treatises on children's diseases should be so remarkably
and unreasonably silent. It certainly cannot be laid to its lacking in
study material, as the author of "Quain's Dictionary of Medicine" says:
"It is one relative to which much might be written without exhausting
the subject, the pathology of which has wide and manifold relations....
There appears to be something analogous between this condition and that
which determines in after life the seminal emissions under similar
circumstances." Our American works are notably deficient in this regard;
although Stewart, of New York, in his "Diseases of Children," published
over fifty years ago, devotes a chapter to dysuria and one to retention
of urine, treating the subject quite fully, even down to the description
of preputial calculi; he, however, failed to notice that the irritation
of preputial constriction or adhesions will produce both conditions,
and, following many of the authors of the time, as has been done since,
he adopted the urino-digestion theory of acid and irritating urine, due
to faulty digestion, of Prout and Magendie, who looked to regulating the
digestion of the child, or the mother who nursed it, as the only method
of cure; the lithic-acid diathesis being, in their opinion, the main
thing to be guarded from.
Other works that mention these conditions are equally on the wide sea of
speculation, as they all, more or less, look upon the treatment that
they advise as indefinite and unsatisfactory, showing an equal want of
sound anchorage-grounds for their etiological reasonings. Dillnberger,
of Vienna, in his hand-book of children's diseases, mentions enuresis,
but has nothing better to offer for its relief than that advised by
Bednar, who followed a systematically-timed period of awakening,
gradually lengthened out, from the time of putting the child to bed. In
addition, he advises internal medication, and, like Ultzmann, he
recognizes the possibility of a local cause in little girls, in whom he
advises the local application of nitrate of silver. Edward Ellis
mentions dysuria, and a long prepuce is noticed among its numerous
causes. The works that give the subject the most intelligent treatment
(the word "intelligent" is here used advisedly, and is in reference to
the results obtained) are those of West, of London, and Henoch, of
Berlin. West, in his "Diseases of Children," says: "In the child,
however, we sometimes find the symptoms produced by difficulty in making
water owing to the length of the prepuce and the extreme narrowness of
its orifice, which may even be scarcely large enough to admit the head
of a pin. This congenital phimosis is, I may add, not an infrequent
occasion of incontinence of urine in children, and is also an exciting
cause of the habit of masturbation, owing to the discomfort and
irritation which it constantly keeps up. In every case, therefore, where
any difficulty attends the passing or the retention of the urine, or
where the practice of masturbation is suspected, the penis ought to be
examined, and circumcision performed if the preputial opening is too
small. This little operation, too, ought never to be delayed, since, if
put off, adhesions are very likely to form between the glans and the
foreskin, which render the necessary surgical proceeding less easy and
more severe."
In the "Lectures on Diseases of Children," Henoch, of Berlin, says: "I
need scarcely add that an examination of the external genitals should
never be omitted in any case of dysuria during childhood. You will not
infrequently discover a phimosis which interferes more or less with the
discharge of urine and retains portions of the latter behind the
foreskin, where it may decompose and give rise to an inflammatory
condition of the prepuce, with painful dysuria.... This is also true of
the occasional adhesion of the labia minora in little girls, like the
similar adhesion of the foreskin in boys. It is almost constant in the
first period of life, but sometimes persists to the end of the first
year; can usually be torn by the handle of the scalpel, and rarely
requires an incision. In a few cases this adhesion appeared to me to be
the cause of the dysuria, which disappeared after the separation of the
labia from one another."
Henoch, however, does not seem to have grasped the full relation that
the natural phimosis of young children bears to dysuria, as he here
follows the prevailing opinion, that where by dint, push, hauling, and
hard work the prepuce can be pushed back phimosis does not exist, as
well as the general apathy to the fact that a prepuce can exert a very
injurious influence by its pressure, even when not adherent and very
retractable; such a prepuce is often attended by balanitis and
posthitis, with an accompanying difficult, frequent, and painful
urination. In a case which will be related farther on, in the discussion
of the systemic effects of a long, contracted prepuce, as it induces
diseased action by continuity of tissues, there is an account of a death
of a two-year-old child which we can assume to have had its original
starting-point in a condition of phimosis. Henoch, however, rather
attributes the death in that case to what may well be considered the
result of a cause, leaving the original cause more to appear as a final
accessory condition.
My reasons for this view of the subject are simply owing to the fact
that I do not believe that a child can long be afflicted with the
_ischuria phimosica_ of Sauvages without having the urinary organs
beyond more or less seriously affected from the mere retention alone,
irrespective of any reflex irritation from the pressure on the glans or
of any from the irritation of the peripheral nerves; the dilatation of
the adjacent cavities or channels and the deposit of calcareous matter
being facilitated by the retention of urine and its naturally altered
condition owing to that retention. So that dysuria in young children,
beginning in a slightly phimosed condition, or in the irritability of
the glans and meatus, due to its preputial covering, it is safe to
assume, may produce a train of symptoms ending in permanently-injured
health, or even death. The irritating urine of a slight access of fever
may, by its passage over the irritable mucous lining of the prepuce, be
the initial starting-point of a serious or fatally-ending disease. In
all of these, it must be admitted, the presence of the prepuce is either
actively or passively the cause of the most serious disease processes
that may follow.
Ultzmann, of Vienna, in his work on the "Neuroses of the Genito-Urinary
Organs," gives the subject of enuresis considerable attention. It is not
a work on diseases of children, but it, nevertheless, goes into the
subject as if it were, and furnishes the profession with considerable
information. He defines enuresis to be the passage of urine of a normal
quality in a child who, with the exception of this involuntary
urination, is healthy. In the first periods of life, a slight vesical or
intestinal expulsive effort is sufficient to overcome the guarding
sphincter muscles at their outlet; the child first obtains a voluntary
control of the rectal sphincter; and, generally, with the second year it
gains control of the vesical. Those who pass their second year without
obtaining this control, but in whom the organs and urine are normal, may
be said to be afflicted with enuresis. He divides enuresis into three
varieties; that involuntary urination which takes place at night during
sleep he terms the _nocturnal_; that which takes place while climbing,
laughing, coughing, or in the course of any violent muscular exercise is
the _diurnal_; and that wherein the involuntary evacuation takes place
day and night alike he terms as the _continued_. This last is again
subdivided into the continuous and periodical. As a cause, he cites
anaemia, scrofula, rachitis; but adds that physical debility is not
necessary for its presence, as well-developed, vigorous, puffy children
are as liable to be affected as thin and scrawny ones; while not all
scrofulous or rachitic children are so affected, only a small portion
being enuretic. Sex has no influence on the liability that tends to
being attacked, the proportion between the sexes being about equal. As
to age, he finds the greatest proportion to be between three and ten
years, but he has often treated those of either sex even at the age of
fourteen and up to seventeen years. It is absolutely necessary to
examine the external genitals and the urine of those affected by this
disease, as phlegmasiae of the vagina, of the vestibule or urethra in
girls, or the practice of onanism, or lithiasis, cystitis, or pyelitis
may be the cause of the disease. Girls are apt to be found affected with
polypoid excrescences at the meatus, which when removed will cause the
enuresis to disappear.
From the above it will be observed that Ultzmann has paid much attention
to these neuroses; but it will also be remarked that neither the
balanitis, collection of infantile smegma, preputial adhesions nor
irritations are taken into any account as possible factors of either
dysuria or enuresis; he has followed more or less an electrical form of
treatment for genito-urinary neuroses, the rectal rheophore being one of
his favorite modes of treating enuresis; in his etiological views of
these disturbances he has adhered more or less to the views of
Trousseau, Bretonneau, and Dessault, who looked upon a debilitated or
anomalous condition of the vesical neck as the cause of the majority of
neuroses in that region.
It may be asked why these celebrated and observing physicians have
neglected the preputial condition, if, as it is claimed, it is, in
itself, so important and sure a factor of the derangements at the
vesical neck? To answer this, or to explain any marked discrepancy that
may occur in medicine between minds equally as acute and observing, it
is but necessary to observe that there is, in medicine, to a certain
extent, a like rule of inheritance, education, with fashion or custom of
habit of thought and practice, as we find in religion. Canon Kingsley
and Froude are equally as acute and discerning as the late Cardinal
Newman, but that did not necessitate their following that prelate into
the foremost ranks of the Catholic Church; and Pere Hyacynthe was
equally as intelligent as Cardinal Newman, but that did not prevent him
from leaving the fold into which the Cardinal had entered from out of
the Reformed Church. Some are born Catholics or Protestants, and are so
with vehemence; others are born in these religions, but are only
lukewarm in their doctrinal observance; while others reason and jump the
traces in either direction. The followers of the destructive theories of
Bronssais could not see the errors of their ways, and neither could they
be made to see the merits of a less interfering form of medical
practice. Trousseau was himself at one time tainted with Bronssaisism,
but, like Paul of Tarsus, he was made to see the error of his way, as he
relates, through a case of gout that he nearly laid out in trying to lay
out the disease antiphlogistically.
I do not assume that preputial irritation is at the bottom of _all_
cases of dysuria or enuresis, any more than it would be rational to deny
that cases of circumcision performed in some cases of diabetic enuresis
have proved fatal as a result of the operative interference; but it is
safe to assume that, in the great number of cases in whom some
irritating conditions were found and removed, the enuresis or dysuria
was due to such preputial irritation. It is also logical to assume, with
West and Henoch, that the organ should in all cases be examined, and its
condition rendered as harmless as possible. That the condition of
preputial irritation has not been fully recognized by all parties as a
cause of enuresis does not do away with the fact that it does exist, any
more than the refusal of the prelates and doctors of Salamanca to listen
to Columbus did away with the fact of the existence of the American
continents.
A. L. Ranney, in his "Lectures on Nervous Diseases," pages 174, 175,
speaks of enuresis in children as being a reflex cachexia, "excessive
stimulation of the centripetal nerves connected with the so-called
'vesical centres' of the spinal cord,"--a condition which may be
produced by either worms in the intestines or by preputial irritation.
Ranney advises a careful exploration of the urethra and rectum in these
cases, and the elimination of all local causes of the conditions.
Probably the most remarkable case of the immediate continuous effects
resulting from phimosis is the one recorded by Vidal, in the fifth
volume of the third edition of his "Surgery." This was a young man with
a congenital phimosis, having but a very small aperture; on an operation
to relieve the phimosis there was a gush of water, but this only fell at
the feet of the patient, without being ejected at any distance; the
urethra was found to have undergone precisely the same dilatation back
of this preputial orifice that it usually undergoes back of a stricture;
the whole urethra from the meatus backward was found to have exceeded
the calibre of that of the vesical neck; the bladder was greatly
dilated.