Diabetes is a condition characterized by polyuria, polydipsia and polyphagia. In many patients the urine also has a high level of sugar. In chronic cases, the patients usually manifest emaciation (Xiao in Chinese) and thirst (Ke in Chinese). Hence, Xiao-Ke is the Chinese medicine terminology for diabetes. However, any other illnesses manifesting thirst and emaciation can be called Xiao-Ke as well. Diabetes is commonly classified into three types according to the Chinese medicine theories: upper, middle and lower. Upper diabetes involves the upper-jiao, and is marked by thirst and polydipsia. Middle diabetes involves the middle-jiao, and is marked by hunger and polyphagia. Lower diabetes involves the lower-jiao, and is marked by thirst and polyuria with turbid urine. (Note: what is commonly called “diabetes” is, strictly speaking, “diabetes mellitus”, that is, “sweet diabetes”. Diabetes mellitus is often also known as “sugar diabetes”.)
Etiology and Pathology
Diabetes may result from a number of causes, including innate weakness, improper diet, emotional imbalance and physical or sexual overindulgence.
With innate weakness of the body constitution the zang viscera are fragile. Of the many varieties, weak constitution with Yin deficiency is especially predisposed to developing diabetes.
Long-term excessive consumption of fatty and spicy foods or alcohol may injure the spleen and the stomach, resulting in the impairment of their transportation and transformation functions. Heat accumulates in the interior and gives rise to Dryness. Dryness injures the fluids, and this in turn leads to diabetes.
Long-term mental over-stimulation may induce stagnation of Qi. Stagnant Qi readily transforms into Fire. Blazing Fire in the interior scorches the lung and the stomach and consumes Yin-fluid. This leads to diabetes.
Excessive physical exertion or excessive sexual indulgence may result in the rise of endogenous deficiency-Fire. “Depletion of water makes Fire more fierce, and fierce Fire makes water more dry.” The result is insufficiency of the kidney, dryness of the lung and heating of the stomach; and together these lead to diabetes.
The common pathological mechanism is dysfunction in the transportation and distribution of body fluids resulting in the rise of Heat-Dryness and Yin deficiency. The main organs involved are the lung, the stomach, the spleen and the kidney. Among them, the kidney is the key organ.
Prolonged Yin deficiency may injure Qi and Yang, so that both Yin and Yang become deficient. In prolonged diabetes the meridians become diseased, and the blood channels may become blocked by static blood.
Moreover, long-lasting diabetes can lead to a number of complications. For example, depletion of kidney-Yin causes the liver to lose its nourishment. When liver essence, kidney essence and blood are insufficient to provide for the eyes and ears, cataract, night blindness and deafness may result. Dryness-Heat scorching Nutritive Yin may cause blood stasis, blockage of the channels and accumulation of poisons as pus. Sores, carbuncles and furuncles may form. Yin deficiency may give rise to severe Dryness and Heat in the interior, which may transform fluids into Phlegm. When Phlegm blocks the meridians and channels, coldness, pain and numbness in the limbs may result. Alternately, Phlegm and blood stasis may lead to angina pectoris or stroke. Yin deficiency may induce Yang deficiency as well. Deficiency of liver and kidney Yang enables water and Dampness to overflow from the vessels of the skin and sinews, producing edema.
Clinical Manifestation
The characteristic manifestation of diabetes includes the “three excesses and one deficit”, namely, polyuria, polydipsia, polyphagia and emaciation. Polyuria may be an increase in the frequency of urination and in the volume of urine produced. It may also involve more frequent urination during the night (nocturia). Polydipsia is the drinking of large amounts of fluids driven by thirst. Polyphagia is the eating of extraordinary amounts of food driven by hunger. In long-lasting diabetes, despite the polydipsia and polyphagia the patient gradually loses weight and becomes progressively more emaciated. In such patients the urine tastes sweet.
The pattern of illness progression differs for children and for adults. In children, the onset and the development of the illness tend to be rapid and the symptoms are usually typical and severe. In serious cases, there may be extreme thirst, headache, vomiting, abdominal pain and hyperpnea (deep and rapid respiration). There may even be coma and collapse. In adults, the onset and development tend to be more gradually, and the symptoms are often atypical. For example, nocturia may be the first or only symptom of diabetes in an adult. In adults, too, the illness tends to develop complications, as described in the previous section.
Key Points of Analysis
The three “excess” symptoms of polyuria, polydipsia and polyphagia usually occur together. However, based on their relative severity and the main location of the illness, diabetes may be classified into upper, middle and lower diabetes. Upper diabetes involves the upper-jiao and is usually due to Dryness and Heat injuring the lung. The most prominent symptom is polydipsia, with mild polyuria and polyphagia. Middle diabetes involves the middle-jiao and is usually due to Heat in the stomach. The most prominent symptom is polyphagia, with mild polyuria and polydipsia. Lower diabetes involves the lower-jiao and is usually due to kidney insufficiency. The most prominent symptom is polyuria, with mild polydipsia and polyphagia.
In general, in the early stages of the illness Dryness and Heat predominate. As the illness progresses Yin deficiency becomes increasingly more important so that Yin deficiency coexists with Dryness-Heat. In the late stages Yin deficiency affects Yang, so that there is Yang deficiency as well.
For most patients, the characteristic “three excesses” make the diagnosis straightforward. Sometimes, however, these symptoms are not prominent and are overshadowed by complications such as cataract and night blindness, carbuncles or furuncles, limb coldness, pain and numbness, angina pectoris or stroke, or edema. In such cases, it is important to inquire carefully into the patient’s urinary, drinking and eating patterns.
Certain symptoms indicate that the illness is very severe. These include facial flushing, headache, agitation, nausea or vomiting, sunken eyes, dry lips with red tongue, hyperpnea and coma. These symptoms usually indicate that Yang and body fluids have been severely depleted, so that the deficient Yang floats to the exterior, and Phlegm and Fire have obscured the upper orifices.
Herbal Treatment
Upper Diabetes (Lung-Heat Injuring Fluids)
Main Symptoms. Prominent thirst and polydipsia, dry mouth and tongue, and polyuria. The tongue coating is thin and yellow, and the pulse is rapid.
Therapeutic Principle. Cool Heat, moisten the lung and generate fluids to stop thirst.
Treatment. Xiao Ke Fan (Diabetes Prescription). Its basic composition is as follows: tianhuafen (Trichosanthes) 20 g, huanglian (Coptis) 10 g, shengdihuang (Rehmannia) 15 g, and ouzhi (Nelumbo) 6 g.
If the mouth is markedly dry, add maimendong (Ophiopogon) and gegen (Pueraria) to enhance the formula’s ability to generate fluids.
Persistent diabetes, frequent urination, rapid and forceless pulse indicate that Lung-Heat has injured fluids so that Qi and Yin are both deficient. Use Yu Quan Wan (Jade Spring Pill) instead. This formula used renshen (Panax), huangqi (Astragalus) and fuling (Poria) to augment Qi and tianhuafen (Trichosanthes), gegen (Pueraria), maimendong (Ophiopogon), wumei (Prunus mume) and gancao (Glycyrrhiza) to cool Heat, generate fluids and stop thirst.
Middle Diabetes (Blazing Stomach-Fire)
Main Symptoms. Hunger and polyphagia, thirst, polyuria, emaciation and constipation. The tongue coating is yellow, and the pulse is slippery, replete and forceful.
Therapeutic Principle. Clear the stomach, purge Fire, nourish Yin and generate fluids.
Treatment. Yu Nu Jian (Jade Maid Prescription). Its basic composition is as follows: shigao (gypsum) 30 g, shudihuang (Rehmannia) 15 g, maimendong (Ophiopogon) 10 g, zhimu (Anemarrhena) 10 g, andniuxi (Achyranthes) 10 g.
If clinically required to cool Heat and purge Fire, add huangbai (Phellodendron) and zhizi (Gardenia jasminoides).
If constipation is severe, first treat with Zeng Ye Cheng Qi Tang (FluidGenerating Qi-Activating Decoction) to moisten the intestines and unblock the intestines. Treat with Yu Nu Jian when defecation has improved.
Lower Diabetes (Impairment of the Kidney)
Deficiency of Kidney-Yin
Main Symptoms. Polyuria with cloudy or sweet-tasting urine; dry mouth and lips; aches and weakness in the knees and waist; dizziness, tinnitus; and dry and itchy skin. The tongue is red, with little coating, and the pulse is threadlike and rapid.
Therapeutic Principle. Nourish Yin, strengthen the kidney, moisten Dryness and stop thirst.
Treatment. Liu Wei Dihuang Wan (Six-Ingredient Rehmannia Pill).
For marked and cloudy polyuria, add yizhiren (Alpinia oxyphylla), sangpiaoxiao (Paratenodera), and wuweizi (Schisandra) to strengthen the kidney and astringe urine.
If endogenous Fire arises, with dehydration and hotness in the five centers (heat filling in the chest, hands and face, etc.), add zhimu (Anemarrhena) and huangbai (Phellodendron) to nourish Yin and purge Fire.
If there are shortness of breath and weakness, with a pale tongue, add huangqi (Astragalus), dangshen (Codonopsis) and huangjing (Polygonatum) to augment Qi.
Deficiency of Yin and Yang
Main Symptoms. Increased frequency of urination, following every drink; cloudy urine; cold-aversion, cold limbs; wan complexion; dry pinna; and impotence or irregular menses. The tongue is pale, with white and dry coating. The pulse is deep, threadlike and forceless.
Therapeutic Principle. Warm Yang, nourish the kidney, strengthen the liver and astringe urine.
Treatment. Shen Qi Wan (kidney-Qi Pill).
Add fupenzi (Rubus chingii), sangpiaoxiao (Paratenodera) and jinyingzi (Rosa laevigata) as clinically appropriate to enhance the ability to nourish Yin, strengthen the kidney and astringe.
For marked aching and weakness of the waist, add duzhong (Eucommia), niuxi (Achyranthes) and xuduan (Dipsacus).
For marked cold-aversion, add lujiao slices (Cervus nippon) and ziheche (human placenta).
For wan and lusterless complexion, add heshouwu (Polygonum), gouqizi (Lycium) and gusuibu (Drynaria fortunei).
For loose feces, add buguzhi (Psoralea) and yizhiren (Alpinia oxyphylla).
Diabetic Complications
Cataract, Night Blindness, Deafness. Treat with Qi Ju Dihuang Wan (Lycium-Chrysanthemum-Rehmannia Pill) or Ming Mu Dihuang Wan (Eye-Clearing Rehmannia Pill) to nourish and restore the liver and the kidney, augment essence and generate blood.
Carbuncles, Furuncles. Treat by cooling Heat and detoxifying poisons. To dissipate lesions and swelling, use Wu Wei Xiao Du Yin (Five-Ingredient Detoxification Drink). During convalescence, emphasize pus drainage and tissue regeneration.
Deficient Yang Floating to Exterior. The main symptoms include worsening of diabetes, headache, nausea, vomiting, red lips and hyperpnea. The tongue is dry. The pulse is threadlike and forceless. The appropriate urgent treatment is to enrich Yin and return Yang to the interior. Use Sheng Mai San (Pulse-Generating Powder) augmented with shanzhuyu (Cornus), tianmendong (Asparagus chochinchinensis), muli (Ostrea) and guiban (Chinemys). If necessary, apply urgent or resuscitative measures from both Chinese and Western Medicine.
Edema, Rheumatism, Stroke, Angina Pectoris. For treatment, see the specific topics.
Acupuncture Treatment
Upper Diabetes. Select the acupoints Shaofu (HT-8), Xinshu (BL-15), Feishu (BL-13) and Taiyuan (LU-9).
Middle Diabetes. Select the acupoints Neiting (ST-44), Pishu (BL-20), Weishu (BL-21) and Sanyinjiao (SP-6).
Lower Diabetes. Select the acupoints Taichong (LR-3), Taixi (KI-3), Ganshu (BL-18) and Shenshu (BL-23).
In all cases, use filiform needles and apply the reducing and reinforcing methods simultaneously.
Case Study
The patient was a 52-year old married male. For over 2 months he had polyuria, polydipsia and polyphagia. Despite polyphagia he would be hungry within 2 h of eating. He also had dry and cracked lips and constipation.
On examination his general condition was fair. He had a red tongue with thin yellow coating and a pulse rate of 80/min. His blood pressure was 135/80 mmHg. The lung was clear to auscultation. The heart border by percussion was at the left mid-clavicular line in the fifth intercostal space. His fasting blood glucose was 220 mg% and his urine contained 3+ glucose.
Diagnosis. Diabetes due to blazing Stomach-Fire.
Therapeutic Principle. Purge Stomach-Fire, augment Qi and nourish Yin.
Treatment and Course. Modified Yu Nu Jian (Jade Maid Prescription) was prescribed. It had the following composition: shigao (gypsum) 20 g, zhimu (Anemar-rhena) 20 g, huanglian (Coptis) 10 g, huangqin (Scutellaria) 10 g, zhizi (Gardenia jasminoides) 5 g, shengdihuang (Rehmannia) 15 g, tianhuafen (Trichosanthes) 20 g, xuanshen (Scrophularia) 15 g, dangshen (Codonopsis) 20 g, huangqi (Astragalus) 10 g, maimendong (Ophiopogon) 20 g, and wuweizi (Schisandra) 10 g.
The dosage of this formula was adjusted up or down depending on the clinical condition. After 25 doses, the fasting blood glucose decreased to 120 mg% and the urine became glucose-free. All symptoms resolved.
