Chapter 6

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.