Enuresis—A method for its study and treatment.

Abstract

IESPITE unremitting efforts, dating from antiquity,' to develop a specific D form of therapy, nocturnal enuresis continues to be generally regarded as an unsolved problem. A review of the several hundred titles constituting the earlier literature on this topic reveals a remarkable array of proposed curative measures, ranging from patent superstitions and magical nostrums to a wide assortment of allegedly scientific methods. Innumerable drugs and hormones;2 special diets (including fresh fruit, caviar, and colon bacilli); restriction of fluids; voluntary exercises in urinary control; injections of physiological saline, sterile water, paraffin and other inert substances; real and sham operations (passage of a bougie, pubic applications of cantharides plasters, cauterization of the neck of the bladder, spinal punctures, tonsillectomy, circumcision, clitoridotomy, etc.) ; 3 high-frequency mechanical vibration and electrical stimulation of various parts of the body; massage, bladder and rectal irrigations; Roentgen and other forms of irradiation; chemical neutralization of the urine; sealing or constriction of the urinary orifice; hydrotherapy; local "freezing" of the external genitalia with ice or "chloratyl"; elevation of the foot of the patient's bed; sleeping on the back; not sleeping on the back; and the use of a hard mattress: these are some of the methods which were commonly recommended and resorted to. In the hands of a limited number of individuals, virtually every method which was proposed seemed to produce cures; but the inability of other persons to obtain equally good results by what appeared to be precisely the same objective procedures eventually made it clear that the effectiveness of these methods was more a function of subtle psychological influences than of the particular physical praxis involved! Following this realization, hypnotism and other forms of suggestion (including various kinds cf placebos) were widely employed for a time; but the results were neither much better nor worse than those obtained by earlier methods, and the A N D * The writers gratefully acknowledge encouragement and numerous courtesies extended by Professor Raymond Dodge, Professor Walter R. Miles, and Mr. Byron T. Hacker during the course of the investigation here reported.1 Goldman (X, p. 247) says: "The ancients were much concerned about the problem [of enuresis] as attested by Pliny, the famous historian, in his Nuturuf History. H e relates: 'The incontinence of urine in infants is checked by giving boiled mice in their food, in fact, this would appear to be the most common folk remedy for this condition. Other remedies are that the child should wear a clean smock at baptism, that the godparents should keep 'their money in their pockets, and among other remedies is the consumption of wood lice and the urine of spayed swine'.'' a Cf. Zappert (55) and Kanner (36).3 For an especially barbaric form of surgical mutilation, see Davis (14). 4 Cf. Davidson (13).

BEHAVIORAL ENGINEERING: POSTURAL CONTROL BY A PORTABLE OPERANT APPARATUS1

“…In summary, the present data showed that the tone was a punisher and that these punishing properties did not derive simply from the information that the tone provided about slouching. Mowrer and Mowrer (1938) also found that noise was an effective punisher but apparently because it awakened the enuretic patient. The present results reveal that a fairly mild tone can serve as a punisher for the waking individual and suggest its use in other behavior applications as an easily programmed stimulus consequence that does not cause the apprehension caused by electric shock (Powell and Azrin, 1968).…”

“…Only one example of this approach seems to have been developed and proven. In treating bedwetting, Mowrer and Mowrer (1938) developed a special bed pad that sounded an annoying tone when urine caused an electrical current to flow through wires imbedded in the pad. The result was that bedwetting decreased.…”

A study in the founding of applied behavior analysis through its publications

“…This criterion excluded the behavior therapy literature based on Pavlov's and Hull's systems (see, e.g., Jones, 1924;Mowrer & Mowrer, 1938;Salter, 1961;Wolpe & Lazarus, 1966), even though Pavlov's science was (and is) included in behavior analysis (see, e.g., Keller & Schoenfeld, 1950, pp. 1-35;Skinner, 1953, pp.…”

“…These include Mary Cover Jones's (1924) article, ''A Laboratory Study of Fear: The Case of Peter,'' which reported eliminating a young boy's fear of rabbits through, in part, Pavlovianbased systematic desensitization (Kazdin, 1978, pp. 130-134;see Jones, 1974); Mowrer and Mowrer's (1938) article, ''Enuresis: A Method for Its Study and Treatment,'' which reported reducing children's nocturnal enuresis with their Hullian-based ''bell-and-pad'' method (Kazdin, 1978, pp. 137-140; see Mellon & McGrath, 2000); and Paul Fuller's (1949) article, ''Operant Conditioning of a Vegetative Human Organism,'' which reported increasing the arm movement of a comatose patient through reinforcement (see Boyle & Greer, 1983).…”

Erratum

“…A reprimand was given when pants wetting occurred whereas positive reinforcement was given for proper toileting. Results with four profoundly retarded children indicated the reliability of the apparatuses in practice and the effectiveness of a toilet training program that used the two apparatuses.Nocturnal incontinence of normal children has received extensive study as a result of which effective treatments based on conditioning procedures have been developed (Mowrer and Mowrer, 1938), refined, and systematically evaluated (see review by Lovibond, 1964 (FALL 1971) …”