The diabetic foot is a diabetic foot or lower extremity with ulcers, bone and joint lesions, and the resulting gangrene, usually due to a combination of infection based on diabetic peripheral neuropathy and peripheral vascular disease. The diabetic foot is the main cause of disability in diabetic patients, with 50% of non-traumatic amputations in the United States and 46% in China. As the incidence of diabetes increases, so does the incidence of diabetic foot. Therefore, we should raise awareness of diabetic foot, strengthen education for high-risk groups, and conduct regular foot examinations to reduce the incidence of diabetic foot and lower the rate of amputation.
Diabetic foot is divided into five grades from mild to severe: Grade 0: no open lesions on the skin, often showing insufficient blood supply to the extremity, cool skin, purple-brown color, numbness, or dullness or loss of sensation with toe or foot deformity, etc., which is a high-risk diabetic foot; Grade I: open lesions on the skin of the extremity, but not yet spread to deep tissues; Grade II: infected lesions have invaded deep muscle tissues, mostly abscesses and sinus tract formation, and more purulent discharge. There are more purulent secretions. However, the tendon ligament is not yet destroyed; Grade III: the tendon ligament tissue is destroyed, purulent discharge and necrotic tissue increase, but the bone is not yet destroyed; Grade IV: severe infection has caused bone destruction, osteomyelitis and bone joint destruction or has formed a pseudo-joint. Wet or dry gangrene occurs in some toes and fingers or hands and feet; Grade V: Wet or dry gangrene spreads to the ankle and lower legs. According to the nature of the ulcer can be further divided into wet gangrene, dry gangrene and mixed gangrene.
1, Chinese medicine on the understanding of diabetic foot diabetic foot belongs to the Chinese medicine thirst disease of concurrent evidence “gangrene”. On the thirst disease patients with “gangrene” there are many ancient Chinese medical treatises. Tang? Sun Simiao’s “Thousand Gold Formula” says, “People who are thirsty, whether they are healed or not, often think about having a big carbuncle, why? A person who is thirsty must die of carbuncles and gangrene in the large bone joints, so the death of a person should be prevented by a large carbuncle. It is written in the book. In the “Treatise on the Origin of the Diseases” of the Sui Dynasty, it is written that there are eight symptoms of thirst, including “carbuncles and gangrene”. Wang Tao of the Tang dynasty wrote in his “Secret Principles of Wai Tai” that “the disease of thirst? Mostly carbuncles and gangrene”. Yuan? According to Zhu Rui Zhang’s “Health Treasure Book”, “people who suffer from thirst develop malignant sores on their feet and knees and cannot be saved until they die”. Yuan? Zhu Zhenheng “Danxi Xinfa” details the clinical symptoms of diabetes gangrene, pointing out that “gangrene is born in the toes of the question, the fingers may be born of the ten fingers is the branch of the viscera, not before the development of gangrene irritable fever, quite similar to thirst, 13 long to develop this disease. Initially born as a little corn yellow bubble, purple skin color, as if cooked red dates, black gas spread, decay extended open, five fingers, and even attack the surface of the foot, as if the soup splashed fire. Ming? Wang Ji “surgical case” recorded a more typical thirst with the development of gangrene, such as: “an anointed sorghum more than 50 years also suffer from this, purple and black, feet lift pain? The next year, he suddenly became thirsty and took raw milk. The following year suddenly thirsty, taking such drugs as the Shengjin more Sheng, with eight pills and healed.” Ming? Chen Shigong “Surgery” day “the gangrene, external rot and internal bad also, this is because of the past thick flavor paste sorghum fumigation of the internal organs, Dan Shi tonic medicine to eliminate scintillation of kidney water, excessive room labor, gas knot essence injury. ? The first thing you need to do is to be thirsty before the sore, to be cold, to be drowsy, to have a dry tongue, to have frequent urination? has become a sore shape withered, the inner black skin scorched, pain like a knife cut, poison transmitted to the toes.” Qing? Wei Zhixiu “continued famous doctor case” contains: “a man, because after taking medicine to do thirst, the left foot big toe suffering from gangrene, purple color does not hurt, if black if purple that is not treated”. The above description shows that ancient physicians have recognized that diabetes can be complicated by gangrene of the limbs, and the description of its symptoms and prognosis is very similar to modern medicine.
The gangrene of thirst disease is an evidence of deficiency and mixed deficiency and reality. This deficiency is due to the long illness of thirst, depletion of qi and yin, and even the loss of yin and yang, yang can not be transferred to the four end of Wenxi. Yang Qi deficiency, blood flow is not smooth, blood stasis within the birth. Or Yin deficiency and dryness, heat burns the blood and blood stasis. Stasis of blood blocking the ligaments, loss of skin nourishment, and invasion of poisonous evil due to trauma, corrupting the meridians, rotting the skin and tendons, resulting in redness, swelling and ulceration of the extremities, or even black necrosis.
2.There are several types of treatment in Chinese medicine
2.1 The internal treatment method is based on the systemic and local manifestations of the patient. Chinese medicine identification of diabetic foot should pay attention to local identification and take into account systemic identification. Local diagnosis is mainly based on skin temperature, skin color and ulcers. Decreased skin temperature is due to deficiency of qi and yang or stagnation of qi and blood. Elevated skin temperature is caused by heat, but there is a distinction between actual and deficiency, with actual cases being caused by damp-heat injection and deficiency being caused by yin deficiency. Pale skin color mostly belongs to blood deficiency, redness belongs to heat, which can be actual heat or deficiency heat. The skin color purple-red or blue-violet is blood stasis, and those who fade when pressed are mostly stasis in the veins, and those who do not fade when pressed are mostly stasis outside the veins. Black color is mostly the color of dead muscle. If the wound surface is ulcerated and rotten, the flesh is not fresh, the pus is foul-smelling, and the burning pain is intense, especially at night, it mostly belongs to the evidence of heat and poison injury to yin. The traumatic surface is dirty and unclear, the pus has a foul odor and bleeds easily, and the circumference of the trauma is purple and dark, mostly due to dampness and heat stagnation, among which the pus is thick in those with heat; in those with dampness, the traumatic surface exudes more fluid and the granulation is edematous. If the ulcer does not heal for a long time, the granulation is grayish white or like a mirror, and the pus is little and thin, it is mostly due to deficiency of both qi and blood.
2.1.1 Blood stasis blocking the ligament type
Symptoms: Most often seen in the pre-necrotic stage. Weakness of the lower extremities, fear of cold, intermittent limping; itching, dry skin without sweating, dry, cracked skin of both feet, callus formation, pale or dark skin with petechiae, loss of hair, thickened toenails; tingling, burning pain, numbness, dullness or loss of sensation at the extremities, feeling of cotton wool or foreign body in the feet. The tongue is light and dark, with thin white coating and a sunken or sunken pulse.
Analysis of the symptoms: Suffering from thirst, Qi and Yin deficiency, Qi deficiency is unable to push the blood vessels to run, Yin deficiency and blood dryness, Qi and blood is not smooth, blood vessels are stagnant, meridians are unfavorable, skin and tendons are not nourished, so the above symptoms appear. Pale and dark tongue, thin white coating, sunken and thin pulse or sunken and stringy pulse are signs of Qi deficiency and blood stasis.
Treatment: Benefit the Qi, open the veins and activate the blood to remove blood stasis. Recipe: Tonic Yang Returning the Five Elements Soup with Addition. Prescription: Astragalus membranaceus 60g, Sang Gui Zhi l0g, Angelica sinensis 15g, Radix Paeonia lactiflora 15g, Chuanxiong rhizoma 15g, Salvia miltiorrhiza 30g, Radix Rehmanniae 15g, Radix Achyranthes bidentata 15g, Radix et Rhizoma sanguinis 15g, Radix Rehmanniae 30g, Radix et Rhizoma l0g.
Addition and subtraction: If the numbness is heavy, add Silphium luo, Loxodendron, etc. If the weakness of the limbs is prominent, add products that strengthen the spleen and kidney, such as 10g of Radix et Rhizoma Ginseng, 10g of Atractylodes Macrocephalae, 15g of Yun Ling, 25g of Morinda citrifoliae.
2.1.2 Yang deficiency and Yin cold type
Symptoms: cold extremities, numbness and pain in the toes, preferring warmth to cold, aggravated by cold. The local skin is pale or purplish, and the symptoms are aggravated after walking. Pale tongue, thin white coating, sluggish or sunken pulse.
Analysis of the symptoms: long-lasting thirst, yin loss and yang, yang deficiency and internal cold, can not warm the four ends, so see the limbs cool; Qi and blood do not run smoothly, do not pass is pain, so see the local skin pale or ecchymosis, symptoms aggravated after walking, numbness and pain in the limbs; cold is a yin evil, easy to hurt yang, so see like warm and bad cold, aggravated by cold; light tongue, thin tongue moss, sunken or sunken pulse are signs of yang deficiency and internal cold.
Treatment: Warming Yang and dispersing cold, and at the same time clearing the pulse. Recipe: Wen Yang Tang.
Prescription: 30g of rehmannia, 10g of deer horn gum, 3g of cinnamon, 3g of ginger char, 10g of white mustard seed, 3g of ephedra, 3g of licorice, plus or minus: for stagnation of qi and blood, add hen’s blood vine, ghost arrow; for local abscess formation, add raw astragalus, soapberry, and panax notoginseng to benefit qi and release pus.
2.1.3 Stasis and toxicity blocking the ligament type
Symptoms: Mostly seen in the ischemic gangrene stage. Gangrene of the extremities, mostly painful, dark and not fresh, necrotic tissue black, poorly defined, with a small amount of pus decay, dark red or reddish red tongue, thin yellow moss, and fine pulse. Analysis of the symptoms: stagnation of heat in the veins and veins, the nodules do not disperse, the meridians are occluded, the skin and tendons are not moistened, the flesh is hot and rotten, and the gangrene becomes toxic, so the gangrene is painful, the pus and rot are generated by Qi and blood, the local Qi is weak and blood is small, the heat and toxicity is slightly limited, so the pus
There is a small amount of decay, insufficient positive qi, stasis and toxicity blocking the ligaments, and the fight between positive and evil is not clear, so the necrotic tissue is not well defined. The tongue is dark red or reddish-red, with thin yellow coating and thin pulse is a sign of blood stasis and heat.
Treatment: To resolve blood stasis and detoxify the blood vessels, to promote blood circulation and relieve pain. Formulation: Si Miao Wu Blood-stasis Tang
Plus or minus. Prescription: Radix Angelicae Sinensis 20g, Radix Paeoniae Alba 15g, Radix Salviae Miltiorrhiza 30g, Radix Achyranthes Bidentatae 15g, Rhizoma Double Flower Vine 30g, Radix et Rhizoma Ginseng 15g, Radix et Rhizoma Pollen 15g, Radix et Rhizoma Red Vine 15g, Radix Glycyrrhiza Uralensis 6g, Radix Andrographis Macrocephalae 15g, Radix Lactobacillus 10g, Radix Astragali 30g.
2.1.4 Damp-heat blockage type
Symptoms: Foot infection or ulcer, local redness, swelling and pain, thick pus and rot, may be accompanied by low fever. The tongue is white or yellowish greasy, and the pulse is slippery. Mostly seen in those with infected restriction.
Analysis of the symptoms: The skin is broken, the evil of dampness and heat is invaded externally and wrestles with the veins, so redness and pain are seen; the skin is broken because the flesh is rotten with heat; dampness and heat are contained within, so low fever is possible. White or yellowish tongue coating and slippery pulse are signs of damp-heat.
Treatment: Clear damp-heat, invigorate blood and detoxify. Recipe: Sanmiao San plus or minus.
Prescription: Atractylodes Macrocephala 15g, Phellodendron Bark 15g, Radix Achyranthes Bidentata 15g, Poria Cocos 30g, Fructus Forsythiae 15g, Fructus Flea 15g, Radix et Rhizoma Umbelliflorum 15g, Semen Coicis 30g, Radix Paeoniae Alba 15g, Radix Angelicae Sinensis 15g, Radix Zeleniae 30g. Add and subtract: If the swelling is severe, add Plantago Ovatae, Radix Angelicae Sinensis. If purulent secretions are abundant and the Qi is obscene, add 12g of tiger scepter and 15g of groundnut to enhance the power of clearing heat and detoxifying. For local flushing and heat lifting, add 10g of Radix Rehmanniae, 10g of Danpi, 15g of Comfrey, and 20g of Sheng Shi
20g to clear heat and cool the blood.
2.1.5 Heat and toxicity
Symptoms: Red, swollen and ulcerated skin at the extremities, deep to the tendons and bones, rotten tendons and flesh, exposed bone, blackened and necrotic, red, swollen and swollen skin around the wound, purulent secretions, thick and yellow, foul-smelling, accompanied by high fever, red and vivid tongue, yellow and dry moss or black moss, and flooding pulse. Most often seen in severe infectious gangrene with systemic toxic symptoms.
Analysis of the symptoms: Stasis and heat in the veins and veins, and the re-infection of evil toxins, the incandescence of heat and toxins, internal invasion of the internal organs, down to the limbs, rotting the skin and bones, so there is redness and ulceration of the extremities, and even black necrosis; heat and toxins, so it can be high fever. The red tongue and yellow greasy moss are signs of dampness and heat.
Treatment: Clearing heat and detoxification, cooling the blood. Prescription: Wu Wei Disinfection Tang with flavor.
Prescription: 30g honeysuckle, 15g wild chrysanthemum, 20g gong ying, 15g zizyphus, 12g purple-backed asparagus, 15g red peony, 10g dandruff, 15g xuan shen, 15g psyllium, 30g adzuki bean. if the rotten tissue is too much, the smell is obscene, add 15g tiger scepter, 30g poria, to detoxify and remove obscenity. After opening and decompression, pus and rot are not discharged smoothly, add 10g of soapberry, 30g of pollen and 10g of dahurica to remove pus. If the pain is more severe and the skin is dark red, add 10g of Guiweiwei and 10g of Lactobacillus to activate blood circulation and relieve pain. If the fever does not subside, with dry mouth and drinking, and constipation, add 30g of gypsum, 10g of Zhi Mu and 10g of rhubarb to relieve heat and relax the bowels.
2.1.6 Insufficient Qi and Blood. Residual evil not yet cleared
Symptoms: In cases where gangrene does not heal for a long time. The traumatic surface is not healed for a long time, the color is not fresh, pale, dark red, pus and rot have been cleaned or a small amount of pus and rot remains, the traumatic surface is dry and less moist, dull or purple, stagnant and lifeless. The skin or muscle around the wound is stiff and less elastic, the sensation is dull, the skin is dry and flaky, or the keratinization is hyperplastic, the color is dark, and there is no sign of growth of granulation at the bottom of the wound. The tongue is reddish or pale, thin, or with teeth marks and cracks on the sides, and the tongue coating is less fluid.
Analysis of symptoms: Prolonged disease, loss of qi and blood, loss of yin and essence, loss of filling of the pulse channels, loss of nourishment of the limbs, lack of qi and inability to detoxify, which may result in gangrene not closing for a long time, rotting flesh does not come off, new flesh does not grow, and it is difficult to heal. The tongue is vivid red or light, thin, or with teeth marks and cracks on the side, and the tongue is coated with less fluid as a sign of deficiency of qi and blood and deficiency of yin and fluid, which is a sign of positive deficiency.
Treatment: Benefit Qi and invigorate Blood, and tonify the toxin to produce muscle. Remedy: Tory Disinfection Soup or Ten Perfect Tonic Pill plus or minus. Prescription: Astragalus membranaceus 60g, Radix Codonopsis pilosulae 15g, Rhizoma Atractylodes Macrocephalae 15g, Radix Rehmanniae 30g, Radix Angelicae Sinensis 15g, Rhizoma Ligustici Chuanxiong 15g, Rhizoma Pollen 15g, Rhizoma Polygonati 15g, Rhizoma Double Flower Vine 30g, Rhizoma Forsythia 15g.
2.2 External treatment
2.2.1 Non-gangrenous stage
For those who have cold and numb feet, pale or pale yellow or purple, a decoction of Chinese herbal medicine can be used to warm the meridians, invigorate blood circulation and relieve pain, soaking in a bath to improve circulation through transdermal absorption of the skin.
External treatment: Chinese herbal decoction bathing and soaking. Herbs: cinnamon stick, transdermal herb, safflower, double flower, dry ginger, pepper, etc. Usage: water temperature 38-42 ℃, soak for 20 minutes.
2.2.2 Gangrene stage
2.2.2.1 Inflammatory phase of wound treatment for diabetic gangrene combined with severe infection, local redness, swelling, heat and pain, tendon rot, pus cavity formation, poor drainage, should be inaugurated to reduce pressure and keep the drainage unobstructed. At the same time, Chinese herbal medicine can be used to clear heat and detoxify, invigorate blood, subdue swelling, and remove decay and pus.
External treatment method: ① Thoroughly open the pus cavity with scissors and drain the pus. ②Soak and wash the pus cavity with Chinese herbs. Herbs: Phellodendron Bark, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma, Radix et Rhizoma. Usage: The water temperature is controlled at about 36℃, with the wound vertically downward, once a day for 20 minutes. Trauma dressing change: use wet gauze of the original solution to build in the pus cavity, keep the drainage open, and change the dressing 1 to 2 times a day.
2.2.2.2 For those whose infection has been controlled, whose local redness and swelling have been reduced, and whose gangrene has been limited, the trauma can be cleared and cleared.
External treatment methods: ① Clearing: remove necrotic tissue. ②Medication change: decoction of Scutellaria baicalensis, Scutellaria cypress, and Mannite can be used, and wet compress with gauze before each medication change, 10-15 minutes each time. According to the amount of pus and decay, choose Qinghe detoxifying lotion, Jiuyi Dan, Wuwu Dan, etc. for changing medicine to detoxify and remove decay.
2. 2. 2.3 The myogenic stage is the stage where the necrotic tissues are mostly removed and the normal tissues at the base are fully revealed.
External treatment method: ① For decaying flesh not yet removed, new flesh does not grow on the wound surface, change the medication with gauze of myogenic Yuhong paste. ②For flesh buds like mirror, pus is little and lightly diluted, use ulcer oil gauze to change medicine. ③When the trauma collapses and does not grow for a long time and the color is obscure, use moxibustion to warm the trauma or use inter-ginger moxibustion.
3.Chinese medicine
3.1 Activate blood circulation and remove blood stasis ① Blood circulation and blood stasis capsule; ② Blood circulation and blood stasis tablet; ③ Blood circulation and blood pain capsule. 5 capsules per dose, 3 times daily. It is used to treat diabetic foot mainly caused by ischemia.
3.2 Capsules for Kidney, Blood and Tendon (internal preparation of Peking Union Medical College Hospital). 5 capsules per dose, 3 times a day. For the treatment of diabetic foot mainly caused by kidney deficiency and blood stasis.
Diabetic foot caused by kidney deficiency and blood stasis.
3.3 Warming the kidney and Yang, Jin Kui Ren Qi Wan (water pill). 20 capsules per dose, 3 times a day. For the treatment of diabetic foot caused by deficiency of kidney yang, mainly due to lack of warmth in the limbs.
Diabetic foot.
3.4 Clearing heat and detoxifying toxins: ①Lian Qiao Defeat Poison Pill; ②Gardenia Golden Flower Pill; ③Ermyo Pill: 6g per dose, 2 to 3 times per 13. It is used to treat diabetic foot caused by internal heat toxicity and damp-heat obstruction.
4 .Preventive care
Raise awareness of diabetic foot and strengthen health education of diabetic patients about diabetic foot knowledge. For patients at high risk of diabetic foot, they should learn how to protect their feet on a daily basis. Since diabetic patients have dull foot sensation and are often unconscious after foot injury, they should check their feet every day to confirm whether there is any laceration or local redness and infection, and if so, seek medical attention promptly.
In choosing shoes and socks for diabetic patients, special attention should be paid to choosing shoes that are loose, soft, lined with spreading, breathable, and have a certain thickness and elasticity of the sole for comfort. When washing feet, special attention should be paid to the water temperature, because a considerable number of patients have reduced or lost foot temperature sensation, so it is easy to be hot water burns. The water temperature when washing the feet should be 35 to 40qC, that is, feel with your hands is warm, temperature sensory retardation of patients, the best to wash the feet by family members first try the water temperature. Wipe the feet with lubricating skin cream to prevent drying and rupture. Patients with diabetic foot often have foot callus, which is a cause that cannot be ignored in the development of diabetic foot. Because callus can act as a foreign body, squeezing deep tissues and causing necrosis, forming cavernous chisel-like ulcers. Therefore, calluses should be treated by a specialist and not ignored or trimmed at will. Patients with foot odor should be treated aggressively, as it is one of the main factors causing skin lesions and infections. After the healing of diabetic foot gangrene, weight bearing and excessive walking of the affected foot should be reduced to avoid injury and cracking of the healing site caused by extrusion and recurrence of the disease.