The Bedwetting Problem
By EMANUEL MILLER, M.A., M.R.C.S., L.R.C.P., D.P.M.
Hon. Director, East London Child Guidance Clinic Psychiatrist, West End Hospital for Nervous Diseases The recent evacuation of children has led to a very appreciable increase of bedwetting amongst those young people who have left their homes for more or less distant stations throughout the country: young people, because the increase has occurred in all age groups from early childhood to adolescence. For this reason it is timely to review the problem, its causes and the methods of cure. The problem merits our closest attention as much loose thinking about it has taken place because of erroneous classification. In consequence, therapeutic methods have not always been wisely applied with the result that parents who expected a cure in cases which were hopeless have been much disappointed or have been, if rarely, surprised at cures when medical men had been pessimistic.
In the first place the term ” enuresis ” has been applied too widely to all cases which have wetted in the absence of any clear organic cause for its occurrence. In general medicine and surgical practice the involuntary voiding of urine by day or by night, or at both periods of the twenty-four hours, can occur in a variety of organic diseases of the nervous system and in certain surgical conditions of the pelvis known particularly to gynaecologists. The conditions of organic disease comprise disease of the spinal cord, congenital {spina bifida) and acquired (disseminated sclerosis, gunshot wound of the spinal cord and the sacral plexus, general paralysis, and some cases of locomotor ataxia, to quote a few outstanding examples). It occurs in certain profound mental disorders such as general paralysis and dementia praecox, and in these cases it is not erroneous to suppose that an element of disturbed volition enters into its occurrence. All these cases, including the wetting of epileptic seizures, must be classed as incontinence and not as enuresis. It is a distinction that is imperative, for it marks off a group of cases with poor, if any, chance of recovery. Furthermore, even in the absence of clear organic disease there are other forms which belong to the incontinent group. In this group are to be found the cases of late development of sphincter control in young children, mental deficiency where training is fruitless, and where there is some inborn lack of motor co-ordination. Such cases of incon- tinence in the absence of organic disease are due to some delay of motor development, and inasmuch as the nervous mechanism is a system of voluntary and involuntary nerve impulses, the source of the control lies in the realm of the instincts as well as in the realm of volition. In fact, the implication of the sympathetic nervous system makes it clear that the glands of internal secretion play their part also in the total pattern of the mechanism which supplies the controlling forces. It is not, therefore, remarkable that children of a subthyroidic endocrine make-up are prone to bedwetting. Such children are torpid, cold handed, paleand easily tired. They respond well to small doses of thyroid gland, and others to belladonna in heavy doses. These medicaments are consequently in the nature of a therapeutic test of diagnosis in a certain type.
The Natural History of Bladder Control
Physical Aspects. In the same way as a child’s nervous system matures to functional perfection from embryonic life to the acquisition of walking and talking, so also it gradually and inevitably acquires control over the muscular apparatus which governs the working of the bladder and the rectum. To a large extent these controls are reflex in character. Head’s work on the Mass Reflex of the spinal cord shows how in spinal injuries above the lumbar region the control of the sphincters is automatic in character arising from the tension of bladder and rectum and stimulation of the cord from a variety of causes. But the control in man eventually assumes a volitional character, that is to say, the cerebrum makes possible the selective control of micturi- tion and defaecation.
The primary reflex discharge can be subject to conditioning. The child can be ” put out ” at certain times. In fact the whole system of nursing of babies (Truby King methods) is a means whereby the child is conditioned to void its bladder under circumstances which are most suited to human cultural requirements. This is what we mean by training. The capacity to accept conditioning is a function of a mature nervous system, both at the level of cerebral control, volitional in character, and in the reflex workings of a developed spinal-sympathetic apparatus. We can well understand from these physical facts that the backward child on the one hand, and the highly excitable child with poor critical control on the other, may be subject to bedwetting and diurnal wetting.
Psycho-somatic Aspects. If the human child were a simple reflex animal subject to very limited conditions the problem of bedwetting would resolve itself into a simple one of incontinence due to poor or delayed maturation and bad conditioning. But the relative complexity of the life of a child, means that this is not so. The atmosphere of training, the methods of training, occasion a variety of circumstances in which a breakdown of control can take place. Moreover, the emotional forces which impinge upon the child from within as well as from without influence his life in many ways, and it is not surprising that the primitive function of micturition should be subject to a variety of influences and shocks. We know how animals in flight are prone to void their urine. We have repeated examples of examination fear producing frequency and even enuresis. We can think of examples of fear even inhibiting the functions of micturition. But these are enuresis of a very elementary kind, and there are few examples of enuresis which can be explained by reference to a regression to such a simple instinctive response. Most cases are much more complicated, although experience gives us examples of sudden shock starting off” intractible wetting which calls for no recondite psychological explanations. We can, however, for a moment mention the simple cases of regression for they probably account for the large number of cases that have occurred amongst the evacuated children. The very fact that these children were, as a rule, restored to normality by change of billets, more comfortable’ sleeping quarters, and by being handed over to more sympathetic charges, proves that the condition was due to a simple breakdown of control occasioned by insecurity and unfamiliarity. Here regression to an infantile uncontrolled reflex voiding of urine was the result of an emotional response becoming easier by the removal of the customary routine, and the absence of the familiar persons upon whom the child relied for emotional support. All the well constructed supports and scaffolds which held up the child’s physical and mental life were unexpectedly removed, and the child fell, as it were, as a person collapses when a familiar splint is taken from him, although his fracture is repaired and his bones are really capable of carrying his weight. Breakdown in confidence no doubt takes place only in cases where the child has all along been living in some insecurity which has been disguised by the supporting world upon which the child was made to rely too much. Furthermore, some of such children were only too prepared to take advantage unconsciously of the removal of restraining influences, moral or disciplinary. Some cases might even be regarded as a sort of sphincter holiday.
The child goes ” native ” as it were. It is not too much to suggest that the recon- struction of a quasi familiar world around the child leads to the reassertion of the pattern of emotional controls which has been temporarily sundered or disturbed. But to cover the whole field of the emotional instinctual conditions which make up enuresis we ought to consider certain aspects of micturition not as they appear to us as adults but as they appear or appeal to the child mind. The child from infancy, as soon as voluntary control is experienced, feels the act of micturition as an urgency which is not unaccompanied by pleasurable feeling. Moreover, the sense of forcible expulsion endows the act with an element of power. It is also a creative act inasmuch as something is actually produced by the child from its own body. Free expulsion of the contents of the bladder is therefore to the child an expression of freedom, power and creativeness, coloured by pleasant feeling tone. It is, in addition, clearly a way of reducing physical tension. So much for the child’s positive contribution to the act. But from an early age it is an act subject to regulation. It is confined to definite times by the mother or nurse, it is governed by a napkin and stimulated by a chamber pot. It very soon becomes an act associated with disapproval and approval, and moreover it is tied up with a part of the body which is private?its exposure is frowned upon. Thus we realize that micturition is not a mere physical act of expelling the rejects of metabolism, but an emotional instinctive process enjoyed by the child and subject to a massive barricade of prohibitions, rewards and punishments. Where resentment is felt against nursing we can picture the child aggressively asserting itself in the act. We can picture the child escaping from responsibility and control by indulging in the act. In sleep, inhibitions imposed by the waking world and its laws and orderliness are relaxed and the child can indulge, perhaps through its dream-fancies, the freedom, power and aggressiveness of the act. It is equally possible that auto-erotic acts denied by the waking life are vicariously satisfied by bedwetting in sleep, particularly during the period of maximum dreamful- ness, when going off to sleep, and at the threshold of waking.
It is obvious, therefore, that before we can fully understand all but the uncomplicated cases of bedwetting we must look into all the circumstances of the early life of the child. That is to say, the method of nursing, the degree of authoritarianism, the atmosphere of moral censureship. In addition, the positive aspects must be considered, the child’s aggressiveness, its desire for love and attention, the sensual attachment to parents and nurses, its degree of loneliness from which the escape into auto-erotism springs. These considerations do not rule out the benefits of hygienic training, sleep habits or metabolic balance in diet. They throw a light on a condition which exists independently of training and level of intelligence.
They tend to focus our attention on those true enuretics who are suffering not from incontinence, the causes of which spring from organic disorders before discussed, but from disturbances of the emotional and instinctual life. To investigate a case, therefore, the family relations must be fully taken into account from excessive love to jealousy of rival, a brother or a sister. We must consider all other symptoms which accompany the enuresis, from temper tantrums and phobias to acts of delinquency. Such a survey of a case can alone relieve those strains and frustrations which lie at the root of this obstinate and embarrassing condition.
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