TREATING PEDIATRIC BED-WETTING WITH ACUPUNCTURE AND CHINESE MEDICINE
by Robert Helmer Blue Poppy Press, paperback, 252 pages

Robert Helmer has done great work here, pulling together a great deal of information that would have otherwise remained scattered in sources that most practitioners do not have easy access to. From the beginning of the book, the approach is systematic. Clear defi nitions are given of Primary Nocturnal Enuresis (PNE) and Secondary Nocturnal Enuresis (SNE), together with some statistics related to age groups of sufferers etc. Herbalists are likely to gain most from this book as the bulk of the Chinese research relates to herbs, with smaller amounts on acupuncture, tuina, combined therapies and the external use of herbs. However there is useful information for all those who treat children. This book has grown out of the fact that Chinese medicine has a great deal to offer in treating this distressing condition. The emotional impact that successful treatment of nocturnal enuresis (NE) has on self-esteem and on the whole dynamics of the family cannot be understated. The psychological factors involved in NE are discussed in the text, along with the less wellknown co-morbidity of NE and Attention Defi cit Hyperactivity Disorder (ADHD) which is about 30%, considerably higher than expected by chance alone. Chapters 3,4 & 5 cover the Western medicine causes, diagnosis and treatment of NE. Research carried out in 1995 indicates that alarm therapy is the only Western modality that shows any persistent effectiveness (the relapse rates for treatment with imipramine and desmopressin are high and at twelve months were no different from an observational group). However many of the cases that present for treatment with acupuncture in our clinics will come from patients for whom alarm therapy has had no success, apart from waking up the rest of the household. Helmer gives an excellent discussion in chapter 6 of the Chinese medical causes and mechanisms of enuresis. Regarding Heart spirit in children he says “ … When the spirit is quiet and tranquil, heart fi re or yang moves downward to the kidney to transform cold water. But when it is disquieted it tends to stir frenetically and counterfl ow upward. Hence, heart fi re and kidney water fail to interact, … In this case, kidney vacuity is the proximate cause of enuresis, but a disquieted heart spirit is a complicating or even causative factor.” Chapter 8, which forms more than half the book, deals with Chinese research on NE, subdivided into sections on ancient formulas, empirical formulas, external treatments, combined treatments, acupuncture, moxibustion, tuina, electroacupuncture and various combinations of treatments. It has some extremely useful discussions of studies made with quite large numbers of patients. Herbalists and those wanting a fuller understanding of the various herbal strategies behind the treatment of this problem will be rewarded with discussion of many different approaches to the use of Chinese herbal medicine. This is of great value to practitioners as it demonstrates that Chinese medicine, as always, is in evolution and that there is a constant refi ning of the practical and effective, informed by the theoretical background. The results of the research in this section, which have mainly been published in respectable Chinese journals are impressive. To give a fl avour of this research, there is a Dr Zhao Ling who says that “ … when there is insuffi ciency of kidney yang, the heart yang is not aroused. This then results in an extremely deep sleep and spontaneous urination. Yu Jin, Shi Chang Pu and Yuan Zhi are used in order to open the heart orifi ces, diffuse the qi, dispel phlegm, arouse the brain and clear the spirit.” Professor Yu Jin-mao, who is a teacher of the author, believes Shi Chang Pu and Yuan Zhi are not very effective and prefers to use Ma Huang to cope with enuresis resulting from deep sleep. He also points out that 30% of enuresis sufferers have a history of recurrent upper respiratory tract infections and simultaneously develop asthma. Dr Xu Xiao-zhou, in discussing the simple but rich prescription (Bu Gu Zhi, Jin Ying Zi, Fang Feng, Gao Ben, Fu Ping Zi, Shi Chang Pu, Gan Cao) used for treatment of 109 cases of enuresis, refers back to Zhang jie-bin’s saying: “to treat water, you must treat the qi, and, to treat the kidneys, you must treat the lungs.” A study by Zhao Guo Ren shows good results with a very straightforward prescription, Gu Quan Yin (Secure the Stream Beverage), which simultaneously regulates the heart, lungs, spleen and kidneys and which he/she has used for more than 20 years. Chapter 7 (‘Treatment based on pattern discrimination’) discusses the Chinese medicine causes and patterns of Journal of Chinese Medicine • Number 83 • February 2007 Reviews 45 disharmony. For a book of this size it would be good to have a bit more discussion here. There is one pattern of disharmony demanding to be articulated with more clarity and that is where phlegm impedes the ascent and descent of clear yang and yin, with the result that the kidneys and heart lose connection, anxiety is woven into the pattern and sleep may become very deep. The relationship between heart, phlegm, spleen, kidney yin and kidney yang, which one sees in practice more often than in the literature, seems to be left out of many Chinese books on NE and daytime enuresis. The role that this dynamic plays is clear in the use of herbs such as Yuan Zhi and Shi Chang Pu discussed in the section on Chinese research. From a neuroanatomical perspective, there is the possibility that taking greater account of the effects on the senses of phlegm and the deeper connections between phlegm production and the yin-yang balance of the zangfu can help establish more useful connections between the central nervous system and the bladder. The result of successful treatment is that the child can wake in time without the disappointment, sadness and frustration resulting from NE. As with any text, there are some sections that it might have been better to omit, for example the bladder training exercises. These might be counterproductive, in that the child may be confused by being asked not to respond clearly to the sensation/pain of a full bladder. Other minor criticisms are that some of the acupuncture treatments are not relevant in the West, for example the use of 28 gauge needles or the point Huiyin REN-1. Herbalists have to be on their guard when reading trials that used certain banned herbs such as Ying Su Ke (Papaveris Pericarpium), Fu Zi (Aconiti Radix lateralis preparata) and higher doses of Ma Huang (Ephedrae Herba) than are allowed in the UK . The comparison trial for imipramine, desmopressin and alarm therapy dates from 1995 and it is to be hoped this book will inspire a further edition with research comparing treatment using acupuncture, herbs, tuina, western herbs etc. in western trials. The acupuncture points suggested are too narrow in range to warrant an acupuncturist buying this book, for example the omission of Lieque LU-7 in treatment of spleenlung qi vacuity pattern of enuresis. This work makes a valuable contribution in helping us understand a condition which is still not very well dealt with by Western medicine. It will form an extremely useful resource for further research, simply by showing which strategies worked well, and it will be an inspiration to any practitioner who works with this sometimes diffi cult complaint. Chinese medicine and all its users will benefi t a great deal from well-researched books like this one.

Tim Martin