ENURESIS
I have dealt in previous chapters with certain common disorders of
conduct in childhood, which show clearly their origin in the
apprehensions of the grown-up people who have charge of the children,
and in the unwise suggestions which they convey to them. The same
forces are at work in the production of enuresis, or bed wetting,
although the matter is here often complicated by the development later
on of a sense of shame and unhappiness in the child. There comes a
time when the child passionately desires to regain control and is
miserable about her failure, until the concentration of her thoughts
on the subject becomes a veritable obsession. Every night she goes to
bed with this only in her mind. Every night she falls asleep,
miserably aware that she will wake to find the bed wetted. The
suggestion impressed in the first place on the mind of the tiny child
by injudicious management has become fixed by the growing sense of
shame and the complete loss of self-confidence.
It is usually taught that a great variety of causes is concerned in
producing enuresis. It is said to be due to a partial asphyxia during
sleep from adenoid vegetation. It is said to be caused by phimosis,
and to be cured by circumcision. It is said that the urine is often
too acid and so irritating that the bladder refuses to retain it for
the usual length of time. It is said that enuresis may be due to a
deficiency of the thyroid secretion, and that it can be cured by
thyroid extract. Such a number of rival causes may make us hesitate to
accept the claims of any one of them. Certainly I have not been able
to satisfy myself that any one of these conditions exercises any
influence at all or is commonly present in cases of enuresis. I think
that if we examine a large number of cases of bed wetting in children
we can come to no other conclusion than that the cause of the trouble
is due to just such a pervasion of suggestion as we have been
considering above.
There are certain points in the behaviour of a child with enuresis
which seem to point to this conclusion.
_(a)_ In the first place, the trouble is seldom serious or very well
developed in early childhood, and the reason for this, I take it, is
that an occasional lapse in a child of perhaps two or three years of
age is usually treated lightly and in the proper spirit of tolerance.
It is only with children a little older that nurses and parents become
distressed and begin unwittingly by urging the child to present the
suggestion to her mind, that the bed may or will be wetted. Hence the
usual history is that control was partially acquired in the second
year, but that, instead of later becoming complete, relapses began to
be more frequent, and that since that time all that can be done seems
only to make matters worse.
_(b)_ In the second place, the influence of suggestion is shown by the
behaviour of the child when removed to a hospital for observation. It
is the invariable experience that the enuresis then promptly stops. In
hospital the attitude of those around the child is entirely different.
She has the comfortable and consoling feeling that in wetting the bed
she is doing exactly what is expected of her. There is even a feeling
that otherwise she is showing herself to be something of a fraud, and
that she has then been admitted to the hospital on false pretences.
Hence, perhaps for the first time in many years, the child is free
from the obsession, and the bed is not wetted.
_(c)_ In the third place, it is easy to recognise in the history of
many of the cases, the ill-effects of circumstances which add new
force to the fear of failure or shake the confidence in the control
which had been regained. Thus a boy, an only child, who had suffered
from enuresis till his seventh year, had regained complete control
till his eleventh year, when he went to school. In his dormitory at
school was a boy who had enuresis, and who was being fined and
punished by the schoolmaster. The enuresis at once reappeared and
continued unchecked so long as he was at school. As might be expected,
school life is very inimical to cure, unless the trouble can be kept
from the knowledge of the other boys. Anything which directly
increases the nervousness of the child--an illness, for example, with
loss of weight and failure of nutrition, or some mental stress, such
as the approach of an examination--is apt to accentuate the enuresis.
_(d)_ In the fourth place, the incontinence sometimes spreads to the
daytime, and the child is wet both by day and night. Further, in bad
cases it is not uncommon to find incontinence of fæces making its
appearance also. These extensions of the fault only take place when
the management continues to be very faulty, when the grown-up people
around them are more than usually distressed and pessimistic, and have
redoubled their expostulations and appeals.
Now these peculiarities of enuresis seem to me only explicable if we
assume that the want of control is due to auto-suggestion, dependent
at the beginning on the unwise attitude adopted towards the fault by
the nurses and parents, and later kept up by the sense of shame and
the mental distress involved.
The forms of treatment which have been recommended from time to time
are, as might be expected, very numerous.
_(a) Operative._--(i) Removal of tonsils and adenoids, (ii)
Circumcision.
_(b) Manipulative._--(i) Injection of saline solution under the skin
in the perineal and pubic regions, with object of lowering the
excitability of the bladder by counter-irritation. (ii) Gradual
distension of the bladder by hydrostatic pressure, (iii) Tilting the
foot of the bed so as to throw the urine to the fundus of the
bladder, in order to protect the sensitive trigone from irritation.
_(c) Educative._--(i) Curtailing the fluid drunk. (ii) Waking the
child at intervals during the night by an alarm clock or otherwise.
(iii) Rewards and punishments.
_(d) Medicinal._--(i) Belladonna. (ii) Thyroid extract.
_(e) By Suggestion._--(i) By simple suggestion. (ii) By hypnotic
suggestion.
I do not think that any single one of these various forms of treatment
outlined under the first four heads has any effect other than to aid
the suggestion of cure which we proffer in adopting it. Removal of
tonsils and adenoid vegetations might conceivably cure an enuresis
which is nocturnal, it cannot account for an incontinence which
spreads to the day. We might believe that to distend the bladder by
hydrostatic pressure was a cure for incontinence of urine, and that it
acted by removing the local cause,--the smallness and contraction of
the bladder,--were it not that the loss of control is so apt to spread
to the rectum as well. There is no evidence that the urine is
peculiarly irritating. Indeed, such evidence as we have goes to show
that, as in some other neuroses, the urine in enuresis is unduly
copious, and of very low specific gravity. Incidentally, we have in
this polyuria a further argument against the view recently advanced
that a small and contracted irritable bladder is the cause of
enuresis. We do, of course, meet with cases of irritable bladder often
enough, but the complaint is then not of incontinence, but always of
the discomfort of having to rise so frequently for micturition.
To deprive the child of fluid, to wake her many times at night, to
tilt the foot of the bed, are devices which may help in the hands of
some one who is confident of his ability to cure the condition and can
communicate the confidence to the child. Carried out hopelessly and
pessimistically by a tired and exasperated mother, they are well
calculated to strengthen the hold which the obsession has on the
child, so that often we meet with a mother who rightly enough
maintains that the more she wakes the child, the oftener the bed is
wet, till she wonders where it all comes from.
The treatment of enuresis to be successful must be conducted through
and by means of the grown-up persons who have the control of the
children. To stop the development of enuresis in early infancy we must
intervene to prevent the concentration of the child's mind on the
difficulty. During the time when control is ordinarily developed, in
the second and third year, judicious management of the child is
essential. The emphasis should be laid upon successes, not upon
failures. For every child his reputation will sway in the balance for
a time. He must be helped and encouraged to self-confidence, not
rendered diffident or self-conscious.
If the case is well established before it comes under our notice, the
mother, the nurse, the schoolmaster, or whoever is responsible for the
child's management, must understand clearly the nature of the trouble.
The suggestion acting on the child's mind must be altered, and
self-confidence restored. The child must learn to see that the thing
is not so desperately tragic. He should be told that the trouble
always gets well, and that it only goes on now because he is worried
about it and keeps thinking of it. If the whole environment of the
child is bad, so that such a change of suggestion is not possible, and
if enuresis is but one of many symptoms of mental or moral
instability, it may be necessary to remove the child and place him
under the influence of some one else. Sometimes the prescription of a
rubber urinal, which the child can slip on at night, is directly
curative. A public school boy, who was about to be sent away from
school for this failing, fortified by the possession of this
apparatus, wrote six months later to say that he knew now that it must
be all worry that caused the trouble, because with the urinal in
position he had not once had the incontinence.
In inveterate cases hypnotic suggestion is always, I think,
successful. It is obvious, however, that in many cases there are
objections to its use. Often enuresis is evidence that the child's
home environment has been at fault, and that his mental and moral
development has been retarded. It is the management which must be
modified or the home, if necessary, changed. Hypnotic suggestion will
make this one symptom disappear promptly enough, but it will rather
perpetuate than combat the cause--that undue susceptibility to
suggestion, which is characteristic alike of the little child and of
many older neuropathic persons.