DISCLAIMER: This article was written when I was fresh out of acupuncture school. I did not have access to a good translation of the shanghanlun or jin gui yao lue, which led me to make an important interpretive error. Unfortunately, none of my editors caught this inaccuracy either. My error involves not realizing that Zhang zhong jing was not referring to diabetes when he used the term xiao ke (wasting thirst) in the JGYL. The New World Press translation of the JGYL does translate xiao ke as diabetes, which is the source of my error. However, this is incorrect, according to the introduction of Paradigm's new translation of the SHL by Wiseman, Mitchell and Feng Ye. I accept Wiseman's authority in this area.
Nevertheless, I have chosen to leave the article in its original form, except that I have boldfaced the first erroneous passage. My reason for this is twofold. First, the mistake exemplifies an important deficiency in our education, which is Chinese language studies. By not having access to a wide range of sources and commentaries, I erred by interpreting a bad translation. It's like a debate in logic class where an apparently sensible argument is based upon a flawed initial premise. Second, the article still presents information not available elsewhere in english and another basic premise remains sound, which is to say that diabetes in the US rarely presents with classic yin xu signs and should be treated accordingly. As with Wang qing ren and his erroneous theories on blood stasis, perhaps something of use can be salvaged from this error. At the very least, let it serve as a warning to others.
EPIDEMIOLOGY AND PATHOPHYSIOLOGY
Diabetes Mellitus (DM) is the 7th leading cause of death in the USA, yet despite many new leads into the etiology of this disease, mortality has not decreased in over three decades. Chinese medical theorists have traditionally described a disease that is similar to some presentations of diabetes; it is called wasting and thirsting syndrome (Chinese: xiaoke bing). However, there is not a one for one correspondence between these two diseases, especially when referring to asymptomatic hyperglycemic patients. In order to explore potentially successful treatment strategies, it will be necessary to understand diabetes from both the modern biomedical and traditional Chinese perspectives. After a presentation of the conventional treatment of DM in modern TCM, the following sections will provide information gleaned from both modern research and classical Chinese sources, information that I hope may provide some useful precedents for the treatment of early stage, asymptomatic, and atypical DM. There are essentially two types of idiopathic DM. This is to be distinguished from secondary DM, that which is caused by other diseases or drug reactions. Type 1 diabetes is called insulin dependent (IDDM). The pancreatic cells which produce insulin are deficient in number (or absent), thus the net insulin production of these islet or beta cells is very low. The resultant hyperglycemia is due to the failure of glucose uptake by cells, which is one of the functions of insulin. Incidentally, hyperglycemia is just about the only common feature of all types of diabetes. IDDM generally presents with the classic polydipsia, polyphagia, and polyuria. The increased blood sugar leads to increased glucose in the urine, which leads to polyuria due to increased osmotic pressure in the kidney tubules. The polyuria stimulates the thirst centers of the brain, leading to polydipsia. The polyphagia is not well understood, but the failure of carbohydrate metabolism may lead to excessive desire to replenish energy sources. Muscle weakness and weight loss are common. Polyphagia with weight loss are common initial signs of IDDM.
The nature of type 2 diabetes is quite different. This type
is called non insulin dependent (NIDDM). While insulin production may
be decreased in NIDDM, this is not always the case, and it is often seen
elevated in the bloodstream. The main factor in this type of DM is the
increased resistance of target cells to the insulin being produced. The
signs and symptoms of NIDDM may or may not include the polydipsia, polyuria,
and polyphagia of IDDM. Weight loss and muscle weakness sometimes present
with this type, but the typical patient (90% of cases) is obese.1 Now,
it is known that obesity alone increases cellular resistance to insulin,
but obese diabetics display this tendency much more markedly. As is now
well known, reducing weight has been shown to lessen NIDDM symptomology.
Both types of diabetes lead to life threatening atherosclerosis, gangrene,
and kidney failure, as well as increased morbidity. Fatal ketoacidosis
is more common in type 1, but is rare, in any event, in the modern age.
NIDDM does not have a viral or autoimmune component, and while it appears to run in families, no genetic marker has been found. 90% of all cases of DM are NIDDM.3 Insulin deficiency is not an early sign of this type of DM, yet insulin production is abnormal in most cases. In fact, hyperglycemia is most often discovered in asymptomatic patients, during routine blood and urine analysis. As stated, target cell resistance is the main factor in NIDDM, however the mechanism for this is unknown. It is generally believed that genetic factors disturb the cell bound insulin from sending its messages appropriately. Insulin, being a peptide molecule, communicates with cells much like neuropeptides in the CNS. Without receiving proper directions, the cells cannot assimilate the glucose, which then remains in the bloodstream. Since tissue resistance to insulin may occur slowly, the drastic symptomology of IDDM is absent. Eventually, the beta cells may wear themselves out attempting to generate ever more insulin, but to no avail. Obesity is known to cause hyperinsulinism, in response to increased tissue resistance, even in the absence of DM. Thus, the combination of obesity with a genetically-based insulin derangement, may reveal latent diabetes.
MODERN TCM STRATEGIES
Most basic TCM texts associate DM with wasting and thirsting disease. In fact, the symptoms of IDDM, as well as later stage NIDDM, closely match the the traditional description of wasting (weight loss) and thirsting (polydipsia). The traditional scheme divides this disease by the three burner theory. In basic TCM texts, upper wasting is characterized by polydipsia predominating, middle wasting by polyphagia, and lower wasting by polyuria. Some modern texts use zang fu terminology to describe the patterns of lung dry heat, stomach dry heat, kidney yin xu, and kidney yang xu. Nevertheless, the resulting selection of formulas is quite similar.
According to the Comprehensive Guide to Chinese Herbal Medicine, a representative basic TCM treatment manual, there are different etiologies to wasting and thirsting disease. The first involves diet.
This description actually sounds a lot like an NIDDM patient, with regard to etiology. Because of diet, such a patient would tend towards damp-heat accumulation, and perhaps obesity, at first. It would only be after a long course that wasting would begin. As we now know, many patients are already well on their way to DM, long before overt symptoms are present. Such a patient would possibly present as suffering from an excess condition, at least in the initial stages of the disease. The slow onset of the disease described above is in contrast to IDDM, which comes on quickly, due to viral exposure. Despite this tantalizing description of NIDDM, the authors do not go on to recommend treatment for this early presentation of thirsting and wasting disease, but limit their formulas to patients with full blown diabetic symptomology. This is true of most basic texts available in English. Other causes, listed in this same text, include emotional disorders (causing constrained qi to transform into fire, leading to yin consumption) and sexual excess, depleting the kidneys. The latter is the most common textbook presentation of wasting thirst; we will revisit the former type below, when considering modern research.
OTHER TRADITIONAL STRATEGIES
Dr. Hong Yen Hsu presents another perspective. Besides making the standard recommendations, he proposes some interesting alternatives. While most of the formulas emphasize nourishing yin and moistening dryness, two formulas are listed for excess conditions. One is the Major Bupleurum Combination/Da Chai Hu Tang, a harmonizing purgative, and the other is Siler and Platycodon Combination/Fang Feng Tong Sheng Tang, a heat clearing purgative.7 They are to be followed with yin tonics/thirst quenchers. Both of these formulas are recommended for weight loss in modern china. Neither of these formulas offers any documented hypoglycemic effect, but perhaps they affect the tissue resistance of the obese NIDDM patient, thus allowing glucose to be assimilated. Clinical research on purgation in the treatment of DM lends some support to this hypothesis.
Wasting and thirsting has also been discussed in a number
of classical texts, including the Dan Xi Zhi Fa Xin Yao by Zhu Dan Xi.
This text was written around the mid 14th century by a great scholar,
who was known as the founder of the School of Yin Tonification. While
Zhu emphasized yin nourishing, he was also a student of the three other
great masters of the Jin and Yuan dynasties; Li Dong Yuan (the school
of spleen and stomach tonification), Liu Wan Su (the school of cool and
cold), and Zhang Zi He (the school of purging). He was also a student
of the Nei Jing and other early classics. Zhu also used the triple burner
scheme in his introduction to wasting thirst. Some of his treatment methods
are precursors of modern TCM, but others seem somewhat unconventional.
According to Zhu, upper wasting includes,
As we can see, both lower and middle wasting thirst, according to Zhu, involved some degree of excess heat (which I have deduced from his recommended treatment principles: purging and heat clearage). This is in contrast to most basic modern texts, which emphasize tonification (especially yin, which was Zhu's favorite). Even when such basic texts focus on heat clearage, the herbs selected are those that clear qi level heat (like anemarrhena/zhi mu and gypsum/shi gao), in which the fluids have already been damaged. While this is appropriate for some patients, Zhu believed this was not always the case. As we shall see, modern research now supports the purging method for some types of DM. And much like Zhu himself, several of the modern research formulas described below combine purgation with yin tonification and heat clearage.
Modern research supports current TCM practice, as several of the herbs in formulas commonly recommended have been shown to lower blood sugar. These include anemarrhena/zhi mu,13 rehmannia/shu di,14 hoelen/fu ling,15 and alisma/ze xie.16 The approaches of Zhu Dan Xi and Zhang Zhong Jing have found their basis, as well. White atractylodes has been found to be a gentle long term hypoglycemic, as has red atractylodes.17 The USDA reports that cinnamon and other hot spices have been shown to increase insulin activity several-fold.18 Thus Hoelen 5 contains four hypoglycemics (cinnamon, white atractylodes, hoelen and alisma). According to Subhuti Dharmananda, studies of alloxan treated mice (alloxan treatment destroys the pancreatic beta cells, thus mimicking DM, especially IDDM) revealed substantial hypoglycemic effect in rehmannia and alisma, but this effect was absent in normal mice. Yet, clinical research has been done using Rehmannia 6/Liu wei di huang wan and Ginseng and Gypsum Combination/Bai Hu Jia Ren Shen Tang; these two formulas were indicated when insulin secretion was normal, despite having DM (i.e. NIDDM). Rehmannia 8/jin gui shen qi wan was indicated for those patients with little or no insulin production (i.e. IDDM). Subhuti Dharmananda reports that Rehmannia 8 may be useful in regulating blood sugar in IDDM patients, but not in actually reducing insulin dependency.19
Several references in the literature have been made
to less standard approaches, as well. Several studies mention the use
of a purgative called Persica and Rhubarb Formula/Tao He Cheng Qi Tang.
In animal studies, this formula was shown to improve the function of the
beta cells, increase secretion of endogenous insulin, and decreases the
secretion of pancreatic glucagon (a hormone produced by the pancreas that
increases blood sugar). Gluconeogenesis (the formation of sugar, which
is then secreted into the blood) is inhibited, while glycogen synthesis
is enhanced. Glycogen is the cellular storage form of glucose, thus its
synthesis extracts sugar from the bloodstream. The net result of all this
is lower blood sugar.20 Another study demonstrated a delay in the thickening
of the renal capillary basement membrane in diabetic mice, thus conferring
protection against the renal complications of the disease.21 A clinical
study of this formula yielded significant to marked improvement in 90%
of the patients.22 According to Bensky, this formula accomplishes its
effects by adding blood vitalizing properties to Tiao Wei Cheng Qi Tang.23
This is a famous purgative that harmonizes the center. In the research
formula, licorice and cinnamon twig serve this function. A clinical study
of NIDDM was also done using herbs to regulate liver qi constraint.24
Herbs to clear yin xu heat were also included, but the authors make it
clear that liver problems due to emotional disharmony were predominant.
Efficacy was 95%, but only partial control could be achieved in almost
75% of the cases. One interesting study combined the principles of clearing
dampheat, quelling fire, cooling blood and invigorating blood, along with
yin moistening and qi tonification.25 Further support is lent to the approach
of dampheat clearage in studies on the successful use of berberine, in
both NIDDM patients and laboratory rats.26 Berberine is a component of
several important herbs (coptis/huang lian, scute/huang qin, and American
goldenseal and Oregon graperoot).
TREATMENT OF HYPERGLYCEMIA
Subhuti Dharmananda has reported that several other herbs of interest have marked hypoglycemic effect. Of these, cyperus/xiang fu, red atractylodes/cangzhu, phaseolus/lu dou and clerodendron were all effective, even in normal mice. Millet, coix/yi yi ren, benincasa/dong gua ren, and alisma (ze xie, already mentioned above) were effective only in mice with damaged pancreatic beta cells.27 To this list I add cornsilk/yu mi xu, traditionally used for wasting thirst, and a clinically efficacious hypoglycemic; this herb drains excess dampness. I have selected these herbs from a larger list of more well known tonics, precisely because these herbs tend to be used in excess conditions, or to treat the manifestations of an illness, rather than the root. Many chronic diseases begin as excess conditions, eventually leading to states of deficiency. We are advised in Fundamentals of Chinese Medicine to clear pathogenic factors prior to tonification, in the relatively strong patient presenting with mainly symptoms of excess.28 With the benefit of modern lab testing, we can now begin treatment of NIDDM prior to the onset of symptomology, when the condition is still one of excess. This is fortunate, as excess is generally considered easier to treat than deficiency. With this information in mind, it is time to reexamine the NIDDM patient.
When a patient presents with the symptomology of wasting
and thirsting, the common strategies clearly apply. But what of the all
too commonly seen patient, the one who has just learned of her hyperglycemia,
despite being asymptomatic? If the modern research is borne out, increased
tissue resistance is the factor that needs addressing, for it is the tissue
resistance that leads to pancreatic failure. Of course, dietary discipline
cannot be overestimated as the solution to NIDDM, however weight loss
is very difficult to achieve for many people. Thus, tissue resistance
has been a major focus in research efforts directed towards NIDDM patients
(beta cell transplantation is a future possibility for IDDM patients).
In light of the preceding information, several nonstandard approaches to the treatment of DM become apparent. A number of hypoglycemic herbs are said to have a fortifying effect on the stomach and spleen (Chinese: jian wei pi) , such as red and white atractylodes, millet, hoelen and coix. That is to say, they promote the assimilative function of the spleen; this to be differentiated from qi tonification (Chinese: bu qi), in which the body is literally supplemented with qi, usually with such herbs as codonopsis and astragalus. While some authorities advise against consumption of starchy foods (like coix and millet) in DM patients, others say it is precisely these slow acting sugars (as opposed to sucrose and lactose), that are needed to restore normal glucose metabolism. The Merck Manual recommends a low fat, high fiber diet, with up to 60% carbohydrate, but no simple sugars.29 The research suggests to me that if the patient presents with the typical indications for spleen fortification and damp transformation (i.e. loose stools, bloating, scalloped tongue, possibly with a thick or wet or greasy coat, slippery pulse), then it would not be remiss to begin with the herbs mentioned. While damp draining may be considered risky in patients who may develop polyuria, it is important to realize that the herbs in question do not actually induce much, if any, diuresis, when given in normal doses. It is always possible that an obese patient will present as yang xu or qi xu, so differentiation should be carefully done.
If the patient presents with constipation, but other signs are excess, and the tongue is thickly coated, purgation is not without precedent. It has been mentioned that neither of Dr. Hsu's selected formulas have demonstrated hypoglycemic activity (though atractylodes is one ingredient of the fairly large Siler and Platycodon Formula/fang feng tong sheng tang, and purgation has proven useful in animal studies-see previous citations). It is worth noting that Zhu Dan Xi often applied purgation in concert with fluid engendering, in which category, several choices are decidedly hypoglycemic (i.e. rehmannia/shu di, ophiopogon/mai men dong, anemarrhena/zhi mu). From Zhu's descriptions, it is also clear that some wasting thirst patients may also present with restricted urination or yellow urination, signs of dampness, and/or heat in the lower warmer. This is confirmed by the modern TCM etiology described above. In this case, perhaps emphasizing the damp draining cornsilk/yu mi xu, benincasa/dong gua ren, hoelen/fu ling, or alisma/ze xie would be appropriate.
In Chinese medicine, it is always important to put practical considerations before dogma. The use of pattern differentiation (Chinese: bian zheng) may suggest approaches other than tonifying yin to treat the initial onset of DM, which often presents with symptoms of excess. This contention is supported by both modern research and classical texts. Once the excess factors have been cleared, then both Zhu and Hsu recommend the use of tonification via moist tonics. This may be appropriate, in light of modern research indicating that tissue resistance (an excess condition) ultimately impairs pancreatic function, leading to decreased production of insulin (a deficiency condition). It is vitally important to control hyperglycemia for the duration of the patient's life, because the serious complications of DM are directly related to increased blood sugar, according to medical consensus. Unfortunately, present therapy for DM, including insulin, has not been shown to alter the progression of these complications. However, as it is well known that yin tonics are difficult to digest in patients with dampness, phlegm, or spleen/stomach xu, it is important that they be administered at the appropriate stage of therapy. Rehmannia 6/liu wei di huang wan is thought to be a well balanced formula for the spleen deficient, yin xu patient. Dioscorea/shan yao, hoelen/fu ling and alisma/ze xie work together to promote spleen and kidney function, preventing dampness accumulation. But if the patient presents with significant accumulation of pathogenic factors, these must be resolved before tonification begins.
It is possible that other circulatory complications would be relieved, as well (retinopathy, neuropathy, varicosities, renal impairment). In the studies involving blood stagnation, rhubarb/da huang was the principal herb utilized for this purpose. Other important blood movers included the ubiquitous persica/tao ren and carthamus/hong hua . As both rhubarb and persica move bowel stagnation , it is not completely clear whether it is the purgation or blood invigoration that is most essential here. A clue may be that at least one study disclosed the use of prepared rhubarb/zhi da huang. Prepared rhubarb (or rhubarb that is long cooked, as is often substituted today) is used when one desires to enhance the blood moving or heat clearing effects of the herb, but minimize the purgative action. However, the purgative properties are not completely eliminated by preparation, and, as mentioned, several authors quoted herein believe purgation may be a desired action in certain manifestations of DM.
TREATMENT STRATEGIES FOR IDDM ONSET
Modern research into both IDDM and certain properties of Chinese herbs may also provide possible approaches to the initial onset of IDDM. If IDDM has a large autoimmune and viral component, one might try antitoxin and blood vitalizing therapies. Blood vitalizing has been shown to be useful in stopping and reversing the progression of damage in other autoimmune diseases. It has also been used as a method of lowering blood sugar and improving pancreatic function, as described above (see discussion of Persica and Carthamus Combination/Tao He Cheng Qi Tang, above). The problem in IDDM is the rapidity of beta cell destruction. On the other hand, though the symptoms come on quickly, there is a window of opportunity for this treatment, before complete destruction of the beta cells has occurred. According to Bensky, salvia/dan shen, a very safe herb, has demonstrated hypoglycemic activity in the short term.30 Strong antitoxin herbs, such as Isatis/ban lan gen, may also prove useful, having demonstrated broad antimicrobial activity.31 Ginseng and Gypsum Combination/bai hu jia ren shen tang, a formula recommended in many modern texts for wasting and thirsting disease, may also be useful in this rapid onset condition. This might particularly be the case if fever has depleted the qi and fluids, yet insulin production has not yet been destroyed (see research cited on page 7, above).
As usual, it is vital to differentiate the presenting
symptoms of the patient before you. If the patient has a family history
of IDDM and/or has the genetic marker mentioned earlier (an HLA histocompatibility
complex), the patient should be treated with herbs, foods, acupuncture,
massage, etc. to strengthen his innate constitution. Such a child should
not be given antitoxin and blood vitalizing herbs, as a matter of course,
unless they are truly indicated. The most important goal is to support
the zheng qi, possibly giving yin or qi tonics, whichever may be appropriate.
Qi xu patients may be susceptible to external invasions of toxin, and
yin xu patients may be susceptible to feverish episodes. However, any
constant disharmony in the system of a diabetically predisposed patient
can provide a window of opportunity for an invasion of toxin. So it would
be best to balance the patient, according the principles of TCM, whatever
his presentation (it may be excess, as well, but the strong genetic component
of IDDM suggests a possible jing deficiency; though it should be noted
that while most IDDM patients have the HLA marker, only half of those
with the marker actually experience IDDM; thus the environmental component
is a major factor in this disease).32 Advice on how to dress and exercise
to prevent external invasion could be of immense value to these patients,
One final use for a combination of blood vitalizing and antitoxin herbs might be herbal prophylaxis of DM. Several times a year, possibly at the change of the seasons, potential IDDM patients could take such herbs to prevent any infection or auotimmune initiation. However, it may be necessary to use a combination of these substances, along with herbs to protect the yin and/or qi, in deficient patients. Whether this approach might be useful at later stages of IDDM is unclear. If the pancreatic beta cells have been completely destroyed, autoimmunity is no longer a prominent factor. However, partial destruction often occurs, and thus blood vitalizing and antitoxin therapies may still have a role to play.
From a TCM perspective, it seems plausible that a sudden severe feverish condition could scorch the fluids, leading to blood stagnation (alternately, a cold pathogen could obstruct the blood, as well). Blood stagnation can have sudden and severe consequences (such as stroke and infarction), so it is not far fetched to expect tissue death in other organs, as a result thereof. It is worth noting the use of cinnamon twig for cold type blood stagnation, as this herb is often used in formulas to treat wind invasion in deficient patients. Thus it may confer some protective benefit to the diabetically predisposed child. The hallmark formula of the Shang Han Lun, Cinnamon combination/gui zhi tang, also includes peony/shao yao. According to Heiner Fruehauf, scholar of classical Chinese medicine at the Institute for Traditional Medicine in Portland, the type of peony used in ancient times was always the red (Chinese: chi shao). Thus, depending on the dosage, gui zhi tang, in its original incarnation, can have substantial blood moving effect. The two formulas mentioned for wasting and thirsting disease in the Jin Gui Yao Lue both contain cinnamon twig (in their original form, at least; modern doctors often substitute cinnamon bark/rou gui when using Rehmannia 8/jin gui shen qi wan). Rehmannia 8 also includes moutan/mu dan pi, another form of peony. Moutan is also said to move the blood, thus this formula contains two blood movers.
Treatment of asymptomatic hyperglycemia is inherently dependent on western laboratory testing procedures, preferably done on a regular basis in those with family histories of DM. Insulin is still generally considered requisite for IDDM patients in China. Thus, it is not recommended to reduce insulin in IDDM patients, except under controlled settings. It is also important to closely monitor blood sugar when experimenting with nonstandard therapies for DM. Several kidney yang tonics have been shown to increase growth of organs, glands, or the entire organism. If growth hormone is involved in these changes, this could be counterproductive, as this hormone increases blood sugar. History also suggests that we limit ourselves to interior warming herbs, like aconite/fu zi or cinnamon bark/rou gui, rather than kidney yang supplements, such as eucommia/du zhong or deer antler/lu rong.
As mentioned, modern advancement in the treatment of NIDDM, indeed, has been focused upon decreasing tissue resistance, along with stimulating pancreatic output. This approach is thus only applicable to those with some insulin production. Oral hypoglycemics (non insulin) are limited at the present time to one type (known as sulfonylureas). Sulfonylureas are thought to work by lowering the glycemic threshold necessary to induce beta cell activity. They may also suppress glucagon by promoting somatostatin release. Enhanced binding to target receptors and synergistic interactions with insulin are other suggested modes of action for these drugs. There is some toxicity and adverse drug interaction associated with these agents, and they do not eliminate the need for future use of insulin (though they do delay it). Some authorities speak highly of oral hypoglycemics, others warn of their dangers (cardiovascular complications may be increased with these agents). All agree that they are of limited use, in mild cases of hyperglycemia, and probably do not not increase life expectancy any more than well controlled diet. This may be because the effective dose range has been difficult to determine, and because the effective dose is probably close to the toxic dose. The Merck Manual advises against their use in asymptomatic NIDDM.33 Chinese herbs clearly fall into the category of oral hypoglycemics, as they do not contain insulin like peptides (though a cursory comparison of chemical components of common hypoglycemic herbs revealed no relationship with sulfonylureas, either). Chinese herbs, administered in concert with lower than normal dose sulfonylureas, may be able to reduce blood sugar safely, possibly lessening the risk of adverse drug effects. Since the herbs function by a variety of unexplained mechanisms, their study may also provide the foundation for new avenues of research into the treatment of DM. There is also considerable evidence suggesting that NIDDM is not a local phenomenon, but a failure of several interrelated neurohormonal regulatory systems.34 This suggestion, along with the aforementioned contradiction against sulfonylureas, reveals a potential niche for Chinese medicine, with its emphasis on restoring normal function and system integration. It also reinforces the main point of this presentation. Pattern discrimination (Chinese: bian zheng) is vitally important in the treatment of DM, as it is in all diseases. Chronic diseases are multifactorial by nature, thus an approach that focuses only on the endpoint pathology (in this case, hyperglycemia) is doomed for failure. One of the great strengths of Chinese medicine is its apparent ability to hold disease processes at bay, by promoting the health of the individual in a general fashion.
1. "Diabetes Mellitus", The Merck Manual,!5th Ed., 1987: p.1071
2. Robbins, Basic Pathology, 4rth Ed., 1987: p. 89
3. Robbins, The Pathological Basis of Disease, 3rd Ed., 1984:p. 973
4. Chen, Comprehensive Guide to Chinese Herbal Medicine,1992: p.285
5. Chen, Ze-Lin, A Comprehensive Guide to Chinese Herbal Medicine, 1992: p.396
6. Bensky, Formulas and Strategies, 1990: p. 167
7. Hsu, Hong-Yen, "Diabetes", Sun Ten Chinese Herbal Information Series,#S8:1989
8. Zhu Dan Xi, Dan Xi Zhi Fa Xin Yao tr. by Yang Shou Zhong, Blue Poppy, 1993: p. 135
9. Chen, Ze-Lin, A Comprehensive Guide to Chinese Herbal Medicine, 1992: p.286
10. Zhu Dan Xi, Dan Xi Zhi Fa Xin Yao tr. by Yang Shou Zhong, Blue Poppy, 1993: p. 136
11. Jin Gui Yao Lue, New World Press, 1987:p.185
12. Ibid, p.185
13. Bensky, Materia Medica, 1986: p.78
14. Ibid, p. 96
15. Ibid, p. 192
16. Ibid, p. 213
17. Chang Hson-mou, Pharmacology and Applications of Chinese Materia Medica , 1987:p.374
18. Anderson, Richard, Ph.D., "Cinnamon, Glucose Tolerance and Diabetes", USDA Report
19. Dharmananda, Subhuti, "Treatment of Diabetes with Chinese Herbs", ITM, 1993
20. ACTA MEDICA SINICA 1991;6(2):92-95
21. ACTA MEDICA SINICA 1990;5(5):345-347
22. JOURNAL OF NEW CHINESE MEDICINE 1988;20(4):53-55.39
23. Bensky, Formulas and Strategies, 1990: p. 313
24. JOURNAL OF BEIJING COLLEGE OF TCM 1991;14(3):36-37
25. NEW JOURNAL OF TRADITIONAL CHINESE MEDICINE 1989;21(2): 20-22
26. JOURNAL OF INTEGRATED TRADITIONAL AND WESTERN MEDICINE 1988;8(12):711-713
27. Dharmananda, Subhuti, "Treatment of Diabetes with Chinese Herbs", ITM
28. Ellis, Wiseman, et. al., Fundamentals of Chinese Medicine, p. 374
29. "Diabetes Mellitus", The Merck Manual,!5th Ed., 1987: p.1075
30. JOURNAL OF TRADITIONAL CHINESE MEDICINE 1989;30 (6): 341-344
31. Bensky, Materia Medica,1986: p. 385
32. Ibid, p. 128
33. Robbins, The Pathological Basis of Disease, 3rd Ed., 1984:p. 975
34. "Diabetes Mellitus", The Merck Manual,!5th Ed., 1987: p.1080
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