Fifty years of enuretic alarms

Enuresis may be defined as an involuntary discharge of urine by day or night, or by both, in the absence of congenital or acquired defects of the central nervous system or urinary tract in a child aged 5 or over. Oppel et al in their study of 859 children showed that 10% were wetting at age 7 and the National Child Development Study of all children born in England during a week in 1958 showed on follow up that approximately 12-5% were wetting at 5 and 10% at 7 years.' 2 Ackerson in 1931 stated that despite unremitting efforts to develop a specific form of treatment nocturnal enuresis continued to be regarded as an unsolved problem.3 In 1950 Crosby commented that medical practitioners had been so discouraged over the results of treatment in the past that there was a widespread tendency to counsel parents 'to wait and let the child grow out of it'.4 By 1958 Wickes was able to find only one report detailing the use of an alarm in the United Kingdom and in 1960 Eysenck claimed that not a single child guidance clinic in the British Isles employed the conditioning treatment for enuresis.5 6 In Canada only 10% of paediatricians at the Montreal Children's Hospital approved of an alarm bell.6 The eminent adult neurologist Walshe in a letter to the Lancet in 1964 was scathing in his criticism of the use of this 'barbarous contraption'.7 Several psychiatrists were of the same opinion and were probably responsible for curtailing its use and development. Werry wrote in 1966 'Although references to conditioning treatment will be found in most orthodox pediatric texts, the method has never really become popular at least in medical circles and is at best regarded as a lastditch treatment'28 Twenty years later, according to Foxman et al, enuresis alarms continued to be recommended by only 3% of American paediatricians.9 It seems appropriate, as the 50th anniversary of Mowrer and Mowrer's excellent paper was celebrated recently,'( that the most successful treatment of nocturnal enuresis to date-that is, the conditioning method-should be reviewed. In 1938, Mowrer and Mowrer argued that 'if some arrangement could be provided so that the sleeping child would be awakened just after the onset of urination, and only at that time, the resulting association of bladder distension and response of awakening and inhibiting further urination should provide precisely the form of training which would seem to be most specifically appropriate'.10 To this end they designed a pad of bronze screening and absorbent cotton fabric which when wet with urine, activated an electric door bell to waken the child. Mowrer and Mowrer used this apparatus for three years before publishing their results, at first believing they had pioneered alarm treatment.'0 In 1936, however, Svordlovsk, a Russian scientist, announced his gift to Soviet motherhood-'a light which flashes when the baby needs changing. Wires attached to strips of tinfoil in a special packet with cloth sandwiched between, becoming a conductor when dampened and presto a light goes on'." Seiger patented a similar apparatus in the United States in 1936.12 A more detailed search of the literature showed that Pfaundler, a German paediatrician, had developed equipment in 1902 to signal by a bell that an infant needed changing. 13 He tried it on an enuretic child for a month with appreciable reduction of wet beds, and stated that, in some cases, the knowledge that urination at night would cause the bell to ring henceforth inhibited this act. Genouville and Remy-Roux both used Pfaundler's method and reported good results.'4 15 Genouville found the sound of the bell almost always inhibited further urination even though it did not at first produce wakening.'4 Although Genouville and Remy-Roux claimed considerable success for their treatment, it failed to be taken up, largely because of the cumbersome nature of the equipment and the fact that a considerable amount of urine (20-30 ml) was necessary to activate the electrodes.'4 15