Ping Zheng

Abstraction: Thirty diabetics patients with lower limb gangrene and infection were treated with herbal formulas that tonify qi, nourish yin, cool the blood, promote blood circulation, clear heat, and detoxify. As well as electroacupuncture with selected acupuncture points based on meridian theory and syndrome differentiation. Additionally, appropriate topical were applied and changed dressing regularly as part of the combined internal and external treatment. To address high blood sugar levels, the patients were administered Western medicine for rapid blood sugar reduction.Satisfactory results were achieved, and no major amputations above the ankle in any of the cases.

Clinically, the number of patients with diabetic gangrene is increasing along with the incidence of diabetes. Due to ischemia, infection, and sometimes accompanying neuritis, the rate of major amputation is often high, reaching 12%- 21%^（1，2）. According to relevant statistics in Europe and the United States, 40-70% of lower limb amputations in developed countries are related to diabetic foot, which greatly exceeds amputations due to trauma. 20% of diabetic patients are hospitalized due to diabetic foot in the US, 50% in the UK, and 10% in India,^（3）According to the China statistics more than 10-20% of diabetic patients have had diabetic foot, so the potential of Traditional Chinese Medicine to treat diabetic ischemic gangrene of limbs seems very important. This was a study of 30 cases of diabetic gangrene which were treated with oral administration and external application of Traditional Chinese Medicine and electroacupuncture. The effects were satisfactory.

1. Clinical data and methods

1.1 Clinical data

30 patients with diabetic gangrene, aged 51 to 80 years, 14 males and 16 females. Gangrene involved the toes (grade 1) in 14 cases, the metatarsal bone (grade 2) in 14 cases, and almost the entire dorsum of foot (grade 3) in 2 cases. The standard for grading was established by the Chinese Committee of Integrative Traditional Chinese and Western Medicine Peripheral Vascular Diseases). The dorsalis pedis arterial pulse was palpable in 4 cases and absent in 26 cases. Fasting blood sugar was between 190mg/ dL and 320mg/ dL. 4 cases were type Ⅰ diabetics, and 26 cases were type Ⅱ.

1.2 Method

1.2.1 Oral herbal decoction:

The decoction is composed of: raw astragalus(Sheng Huang Qi), Radix Pseudostellariae(Tai Zi Shen), corn silk (Yu Mi Xu), trichosanthum pollen (Tian Hua Fen), rehmannia root(Sheng Di), anemarrhenae(Zhi Mu), red peony root(Chi Shao), salvia miltiorrhiza (Dan Shen), dandelion (Pu gong Ying), Buttercup (Di ding Cao), and achyranthes bidentata (Niu Xi). For dampness, add Herba Agastaches (Huo Xiang), Atractylodes atractylodes (Cang Zhu), and Alisma (Ze Xie), For severe heat, add coptis(Huang Lian), for severe pain, add Corydalis (Yan Hu Suo), for patients with arteriosclerosis, add Guangyujin(Guang Yu Jin), Prunella vulgaris (Xia Ku Cao), and unprocessed oyster shell (Sheng Mu Li).

1.2.2 Electroacupuncture^（4）

1.2.2.1 Selection of acupoints: select acupoints along the channels according to the location of pain and ischemic symptoms. For example, in the case of pain in the first toe, select adjacent acupoints along the Spleen Meridian of Foot Taiyin and Liver Meridian of Foot Jueyin, and choose Tai Bai (SP3) And Tai Chong (Liv3), 2nd and 3rd toe pain, choose Jie Xi (St 41) and Xian Gu (St43) along the Stomach Meridian of Foot Yangming. In each treatment needle 4-6 acupoints on this basis, combining them points selected to reflect the condition of the patient as a whole. For example, with damp-heat and blood stasis add Qu Chi (L11), Yin Ling (Sp 9), Xue Hai (Sp10) to clear heat and dampness and promote blood circulation. Add Yang Chi(Sj4), Tai Xi (K3) to warm the channels to expel cold, and Zu San Li (St 36) and San Yin Jiao (Sp 6) to replenish Qi and blood when they are deficient.

1.2.2.2 Number of acupoints: Needles should be limited to 4-6 acupoints on each side of the limb at each treatment, not too many. It is important to get needle sensation (deqi) when inserting and manipulating the needle.

1.2.2.3 Electrical stimulation intensity: The frequency should be fast, and the intensity should be gradually increased from weak to strong, but it should not cause muscle twitching.

1.2.2.4 Treatment frequency and course of treatment: Once a day, or every other day, for at least half an hour each time. Ten treatments is a single course of treatment, after five days of recovery, start the next course of treatment.

1.2.3 External application with herbs ointment

Commonly used are Hutu ointment, Bashi ointment, sometimes mixed with powders such as Taohuasan, Jiuyidan, Shengjisan, etc.When changing the dressing, pay close attention to the drainage of the pus to prevent the pus from eroding the surrounding normal tissues and causing deep tissue infection along the tendons. The dressing must be changed every day. One should debride necrotic tissue without causing bleeding or affecting deeper layers of tissue. The necrotic tissue is removed in stages every time the dressing is changed, which is the so-called “ stepwise reduction method”.

For those with good granulation and skin growth and no bone and tendon exposure, Herbs powder and ointment can be used to promote healing.

For those with bone and tendon exposure, one should wait for the a clearly demarcated wound, when the granulation is fresh, and there is no redness and swelling in the proximal limb. Then the wound can be thoroughly debrided, and the tendon and bone stumps should be carefully handled. According to the blood supply of the skin flap, it can be sutured or opened. The western medical dressing method is used to suture the wound, and the western medical dressing method can be used for the open wound at first, and then the herbs ointment dressing can be used to promote healing after the wound has been stabilized.

2. Results

2.1 After the treatment of 30 cases of diabetic gangrene none required major amputation (amputation at the thigh or calf above the ankle).In all cases the gangrene lesions did not spread proximally. The gangrenous tissues gradually sloughed off, and the wounds healed well with the combination of regulation of blood sugar, Traditional Chinese medicine, electroacupuncture therapy and correct dressing changes.

2.2. Typical case reports:

Wang xx, 56 years old, male

Chief complaint: Recent diabetes diagnosis, with an ulcer on the second toe ulcer of the left foot, which spread rapidly to the dorsum and central sole over the course about little bit more than a month.

Medical history: Over a month before intake, the patient found the ulcer on the left second toe, which had rapidly developed to affect nearly the entire dorsum and center of the sole of the foot. He felt feverish. Recently, he’d been experiencing strong constant thirst and urinating frequently, and was diagnosed with diabetes. Five years previously, he’d suffered from high blood pressure and hemiplegia.

Physical examination: temperature 38°C, blood pressure 150/90mmH, heart rate 107 beats/min. General condition was poor, and his face had a pained expression. There was dry gangrene on the extremity of the five toes of the left foot, and wet gangrene at the proximal parts, covering more than half of the dorsum of the foot and the central part of the sole (See pictures). The boundary of ulceration was not clear. There was pitting edema and redness on the left ankle. The left posterior tibial artery was not palpable, and the popliteal pulse was weak. Tongue color was light red, and the fur was white and thick. Fasting blood sugar was 197mg, urinary sugar was ++++.Doppler vascular ultrasonography revealed occlusion of the left dorsalis pedis and posterior tibial arteries, and a partial occlusion of left popliteal artery.

Diagnosis: Diabetic gangrene of the left foot

Treatment:

1). Oral Chinese medicine decoction: Raw Astragalus (Sheng Huang Qi)12g, Radix Pseudostellariae（Tai Zi Sheng） 30g, Corn silk (Yu Mi Xu) 30g, Trichosanthemi pollen (Tian Hua Fen)12g, Rehmannia root(Sheng Di)12g, Anemarrhena (Zhi Mu)12g, red peony root （Chi Shao） 9g, Salvia miltiorrhiza （Dan Shen) 12g, Danpi (Mu Dan Pi) 12g, Gardenia (Zhi Zi) 12g, Agastaches (Huo Xiang) 12g, Atractylodes (Chang Zhu) 9g, Polygonatum (Huang Jing) 9g, Alisma (Ze Xie)12g, Achyranthes bidentata (Niu Xi)12g, one batch per day.

2). Electroacupuncture treatment: Acupoints selected according to the meridians and pattern diagnosis: Zu San Li (St36), San Yin Jiao (Sp6), Tai Xi (K3), Fu Liu (K7), Yin Ling (Sp9), Jue Gu (GB39), Xue Hai (Sp10), Liang Qiu (St34) and other acupoints, stimulated on alternate treatments with electroacupuncture .

3. Discuss

Diabetes mellitus is a metabolic and endocrine disease common in middle-aged and elderly people. Diabetic foot is one of the serious complications of diabetes. The WHO in 1999 defined “diabetic foot” as the coexistence of the three neuropathy, vascular disease, and infection in the extremity. However, in the clinical setting, foot ulcers or gangrene caused by or concurrent with diabetes alone are included in the diabetic foot diagnosis. What we treat here is ischemic gangrene and infection of lower extremities caused by diabetes.

The mechanism of diabetic gangrene in middle-aged and elderly people is considered in TCM to be the deficiency of both qi and yin, accumulation of dryness and heat, blood stasis blocking the vessels, and accumulation of toxins which forms suppurative gangrene.

Regarding blood stasis, studies have shown that in diabetic patients, microcirculation is impaired, blood cells aggregate, and blood flow slows down. The treatment principle is to invigorate qi and return to yin, promote blood circulation and eliminate blood stasis, clear heat and detoxify. In the decoction, raw Radix Astragalus (Sheng Huang Qi) and Radix Pseudostellaria (Tai Zi Shen) greatly nourish vitality; corn silk (Yu Mi Xu), trichosanthin pollen (Tian Hua Fen), rehmannia root(Sheng Di),Anemarrhena (Zhi Mu), nourishes yin and promotes body fluid; Radix Paeoniae Rubra（Chi Shao), Cortex Paeonolium (Mu Dan Pi), and Salvia miltiorrhiza (Dan Shen) clear away heat, 〖JP2〗promote blood circulation and remove stasis, disinhibit the qi and blood, dissipate heat and poison; Corn silk (Yu Mi Xu ) can help lower blood sugar, clear blood heat and facilitate urination; Dandelion and Bettercup (di ding cao)clear heat and detoxify. Achyranthes bidentata (Niu Xi) moves the effect of the above herbs to the lower limb. Therefore, the compatibility of various herbs is consistent with the pathogenesis of diabetic gangrene infection.

Regarding electroacupuncture therapy, experiments have proven that its effects are:

1) Promoting blood circulation. Our study found that the blood flow of the affected limbs can increase after acupuncture (compared with before acupuncture, p<0.005-0.001);

2) Produce endogenous opioid mediators^（5）: Studies have shown that injecting the cerebrospinal fluid of acupuncture-treated rabbits into non-acupuncture-treated rabbits, analgesic effects were observed in the recipient rabbits, which indicates that acupuncture may release analgesic mediators In cerebrospinal fluid, produce analgesic effect;

3) Nerve mediators are involved in the acupuncture effect^（6）: some studies have shown that: muscle pain relief is due to the enhanced release of acetylcholine, and acupuncture stimulates the activation of cholinergics, dilating blood vessels, improving blood flow, and pain relief;

4) Anti-inflammation^（7）: Acupuncture can enhance the immune function of the body, and at the same time, it can inhibit the excessive increase of inflammatory vascular permeability and excessive migration and infiltration of white blood cells, improve microvascular and lymphatic circulation, and promote the absorption of inflammatory exudate. In order to control the scope of necrosis of the inflammatory focus and decrease overall inflammation;

5) It has a two-way adjustment effect on the immune system^（8）: it can not only mobilize the insufficient immune components, but also suppress excessive immune responses, and has regulatory effects on T lymphocytes, serum immunoglobulins, interleukins and other cytokines, eosinophils, etc.

To sum up, acupuncture treatment is not only effective in an experiential clinical setting, but also has an experimentally supported basis for improving this condition.

The external application of Traditional Chinese Medical ointments and powders can aid in the removal of corrupt tissues, and help the granulation regrowth and skin and flesh. Laboratory findings indicate that the herbs in the ointments and powders we used have good bactericidal effects on various pathogenic bacteria (see table).Internal treatment with herbal decoctions can be combined with external treatment so as to strengthen the body and eliminate pathogenic factors^（9）; If the blood sugar is too high, more attention should be paid to rapidly decreasing the blood sugar with Western medicine. The combination of Chinese and Western medicine can control blood sugar in time, which is conducive to controlling the condition and obtaining better treatment effects for diabetic lower extremity gangrene.

Attached:

Ingredients of the author’s homemade Hutu paste: Atractylodes, Cortex Cortex, Corydalis Corydalis, calcined gypsum, calamine.

References

1. Dereck L Hunt, Diabetes: foot ulcers and amputations BMJ Clin Evid 2011 Aug 26;2011:0602.

2. Natasha C Farhanul H Ravi R et al. Lower Limb Amputation Rates in Patients With Diabetes and an Infected Foot Ulcer: A Prospective Observational Study.

Wound Management & Prevention 2021;67(7):22–303.

3. 王嘉桔： 有關糖尿病足的幾個臨床問題。 外科雜誌2008年4（1）：1-8

4. 鄭萍: 中西醫結合治療血栓閉塞性脈管炎107例臨床治療觀察, 中西醫結合雜誌, 1988, 8(11): 665-668

Ping Zheng: Treatment with WM and TCM. of Thromboangiitis obliterance (107 cases). Chinese Journal of Integrated Traditional Chinese Medicine and Western Medicine. 1988 8(11): 665

5. Kawakita, Kenj et al. Mechanisms of action of acupuncture for chronic pain relief – polymodal receptors are the key candidates, Acupuncture in Medicine, 2006 Supplement, 24:58-66.

6. Shen, Joannie. Research on the Neurophysiological Mechanisms of Acupuncture: Review of Selected Studies and Methodological Issues, Journal of Alternative & Complementary Medicine, 2001( Supplement 1), 7 ( 6): 121-127.

7. Qu fan et al. effect of the analgesics mechanism of acupuncture on endometriosis, Oriental Medicine Journal, 2006, 14 (6,) : 26-27.

8. 李錦宇等. 針灸免疫研究概況, 動物醫學進展, 2008, 11 ：107-119

Jinyu Li et al. Overview of Acupuncture Immunology Research, Advances in Veterinary Medicine, 2008, 11: 107-119

9. 鄭萍：肢體潰瘍創面的外用中醫治療 新醫學1978 9:451

Ping Zheng: External application of traditional Chinese medicine for the treatment of extremity ulcer wounds New Medicine 1978 9:451

About the Author:

Professor Ping Zheng: formerly Shanghai Second Medical University Ruijin Hospital; now Portia Clinic, California, USA