Traditional Chinese Medicine Treatment of Ischemic Lower Extremity Gangrene in Diabetic Patients

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

糖尿病下肢缺血性壞疽的中醫治療

鄭萍

摘要：30位糖尿病患者下肢壞疽感染者經中醫中藥益氣養陰、涼血活血、清熱解毒方劑的內服，配以循經取穴、辨證取穴的電針強刺激療法，合適的外用敷 藥、換藥的內外合治，血糖過高則結合西藥快速降糖，獲得較為滿意效果，無1例行踝上大截肢。

臨床上糖尿病壞疽的患者隨著糖尿病的增多而日益增多, 由於缺血、感染和時伴有神經炎，常使大截肢率較高，達12%-21% ^（1，2）。根據歐美相關資料統計,發展中國家40-70%的下肢截肢與糖尿病足有關，遠超過因車禍外傷等因素所致的肢體殘障。 糖尿病患者因糖尿病足而住院者在美國為20%,英國為50%,印度為10%, ⁽³⁾中國的統計，已經超過10-20％糖尿病患者發生過糖尿病足，所以對糖尿病伴發的肢體缺 血壞疽的中醫治療顯得十分重要。 現總結30位糖尿病壞疽患者以中藥內服外敷及電針治療，效果較滿意。

1.臨床資料與方法

1.1 臨床資料

糖尿病壞疽患者30例，年齡51～80歲，男14例，女16例。 壞疽累及足趾（1級）14例，涉及蹠骨（2級）14例，涉及幾近全足背（3級）2例（分級根據中國中西醫結合周圍血管病專葉委員會制定標準）。 足背動脈搏動4例可捫及，26例未捫及。 空腹血糖介於 190 毫克/ dL 至320 毫克/ dL之間。 （4例……為Ⅰ型糖尿病,26例為Ⅱ型)。

1.2 方法

1.2.1 內服中藥煎劑

其湯劑基本組成為: 生黃耆、太子參、玉米鬚、天花粉、生地、知母、赤芍、丹參、蒲公英、地丁草、牛膝辨證論治，濕甚者加藿香、蒼術、澤瀉， 熱甚者加黃連，劇烈疼痛者加延胡索，伴隨動脈硬化患者加廣玉金、夏枯草、生牡蠣。

1.2.2 電針治療^（4）

1.2.2.1 穴位的選擇:根據疼痛和缺血症狀的位置，作循經取穴，例如，在第一趾疼痛，沿足太陰脾經和足厥陰肝經選擇鄰近穴位，選擇太白（ Sp 3 ）和太衝（Liv 3）, 第二和第三腳趾疼痛，選擇沿足陽明胃經的解溪（St 41）和陷谷（St 43）。每一次治療需要4-6個穴位，並結合全身辨證施治進行選穴,如濕熱瘀阻型, 加用曲池(L11)，陰陵(Sp 9)，血海(Sp10)以清熱利濕涼血； 如虛寒瘀阻型加用 陽池（SJ 4）,太谿(K3)以溫經逐寒；如氣血兩虛型加用足三里(St 36)，三陰交(Sp 6)以補益氣血。

1.2.2.2 取穴數：每次每邊肢體4-6個穴位，不宜過多， 關鍵在於 紮針時要有針感（得氣）。

1.2.2.3 刺激強度：頻率以快為佳，強度從弱逐漸增強，以強為好，但不宜引起肌肉抽搐感。

1.2.2.4 治療頻率與療程：每日或隔日一次，每次最少半小時，10次為一療程，休息五天後再做第二療程。

1.2.3 中藥外敷膏

常用的有糊塗膏、八濕膏，有時會摻入桃花散、九一丹、生肌 散等散劑，可依病情選用。 換藥時應密切注意膿液的引流，嚴防膿液浸蝕週埯正常組織和沿肌腱引發深部組織感染，必須每日換藥，當壞疽被藥物軟化疏鬆後，將浮痂和壞腐組織逐步清除， 清除範圍以不使滲血、不干擾深部組織為宜。 每次換藥將鬆動的壞死組織分期分批進行清除,不急於求成，即所謂蠶食法。

對肉芽生長良好,無骨質與肌腱暴露的可先後選用有生肌、長皮、收口作用的丹散與油膏,促進創面癒合；

對有骨質與肌腱暴露的, 待壞死分界清楚，肉芽鮮活, 肢體近端無紅腫者，可進行傷面修整和徹底清創，術中仔細處理肌腱與骨殘端。 依皮瓣血液供應情況等，或縫合，或開放，縫合創面採用西醫換藥法，開放創面可先用西醫換藥法，過渡到中藥換藥而促進癒合。

2. 結果

2.1 治療後，30位糖尿病壞疽者無需大截肢（踝部以上大腿或小腿部位的截肢）。 所有的壞疽經治療後未見病灶擴大向上，已存在的壞疽在控制血糖、中藥服用、電針療法及正確換藥下，壞死組逐漸脫落，肉芽、皮膚新生而癒合，或在症情改善後 作擴創術,正確處理暴露骨頭和肌腱，也能逐漸癒合。

2.2. 典型案例報告

王xx, 56 歲, 男性

主訴: 近來發現有糖尿病,近一個月左腳第二趾破潰後迅速擴散至足背及足心。

病史:1個多月前，患者發現左足第2腳趾潰瘍，並迅速發展為幾乎整個足背和足心，自感有低燒或高燒。 最近感覺煩渴多尿,查出有糖尿病 ,五年前,患有高血壓和偏癱。

身體檢查: 體溫38℃，血壓150/90mmH，心跳107次/分。 一般狀況差，疼苦狀。 左足遠端五趾有乾性壞疽，近端有濕性壞疽, 達全足背一半以上，足底達足心。 潰瘍創面界限尚不夠清楚。 左踝部位微紅有凹陷性水腫。 左脛後動脈未觸及，左膕動脈搏動減弱， 舌色淡紅，苔白而厚。 空腹血糖為 197mg%，尿糖為 ++++。 多普勒血管超音波檢測顯示左足背動脈和脛後動脈阻塞, 左膕動脈部分阻塞。

診斷： 左腳糖尿病性壞疽

治療

1）內服中藥煎劑：生黃耆12g，太子參30g，玉米須30g，天花粉12g、生地12g、知母12g、赤芍9g、丹參12g、丹皮12g、梔子12g 、藿香12g，手術9g ，黃精9g，澤瀉12g，牛膝12g，每日一帖。

2）電針治療：依循經取穴及証情取穴，取足三里、三陰交、太谿、復溜、陰陵、絕骨、血海、梁丘等穴位，輪流電針強刺激。

3）西藥：D860，每日3次，每次1片。 治療一個月後，劑量減至每天一片。

4）外敷中藥膏：以九一丹、八濕膏每日換藥,肉芽生長時可改用生肌散、糊塗膏外敷。

治療結果：治療7天后， 潰瘍邊界清楚，踝部紅腫消退 。 21天后，壞疽逐漸軟化，並作部分清除。 尿糖轉陰。 D860 的劑量減少到每天一片。 治療3個月後，在局部麻醉下，透過外科手術沿著潰瘍邊緣切除暴露的壞死骨，正確處理肌腱。 手術後一個月，潰瘍癒合，保留了足的大部分正常組織，避免了大截肢。 一般狀況好轉， 複查血糖、尿糖正常。

治療前患足背與足底壞疽感染況

治療後保全了大部分足部

3. 討論

糖尿病是一種常見於中老年人的代謝和內分泌疾病。 糖尿病足是糖尿病患者的嚴重併發症之一。 1999年WHO所下的定義，三者（肢體神經病變、肢體血管病變、肢體感染）共存謂之糖尿病足。 但在實際診斷中把糖尿病單一引起的足潰瘍或壞疽都列入了糖尿病足。 我們在這裡治療的是糖尿病引起的下肢缺血壞疽與感染。

從中醫觀點來看,中老年人糖尿病壞疽的機制可認為是氣陰兩虛，燥熱蘊結，血瘀阻脈，毒聚而成化膿性壞疽。

關於血瘀，研究表明，糖尿病患者微循環受損，血球聚集，血流速度減慢。 治療原則是補氣回陰，活血化瘀，清熱解毒。

湯劑中生黃耆、太子參大補元氣；玉米鬚、天花粉、生地、知母補陰生津；赤芍、丹皮、丹參清熱行血活血化瘀,使氣血通暢，熱毒得散；玉米須可助降血糖，清血熱利小便；蒲公英、地丁草清熱解毒；牛膝引藥下肢。 因此，配伍諸藥正中糖尿病壞疽感染之病機。

關於電針療法，實驗已經証明其作用有：

1）可促進血液循環，我們研究發現針刺後受累肢體的血流可增加(與針刺前相比，p<0.005-0.001)；

2)產生內源性鴉片類介質^（5），有研究顯示，把針灸治療的兔的腦脊髓液注入未針灸治療兔，在受體的兔身上，觀察到鎮痛作用, 這表明針灸可能釋放 鎮痛介質在腦脊髓液,產生鎮痛效果；

3)神經介質參與針刺效應^（6）：一些研究顯示: 肌肉疼痛緩解是由於乙醯膽鹼的釋放增強，針刺激活了膽鹼能，使血管擴張,血流改善，疼痛緩解；

4)可抗發炎^（7）：針刺能增強身體免疫功能,同時,又可抑制發炎性血管通透性過度增高和白血球過多遊出與浸潤，改善微血管和淋巴循環，促進發炎性滲出物吸收，進而控制發炎病灶的壞死範圍，使發炎消退；

5)對免疫系統有雙向調整作用^（8）:既能調動免疫成份的不足,又可以抑制過度的免疫反應,對T淋巴細胞、血清免疫球蛋白、白介素等細胞因子、嗜酸粒細胞等均 有調整效用。

綜上所述，針刺治療不僅實際上有效，也是有其理論依據的。

中藥油膏和散劑的外用，可去腐生新，有助於肉芽和皮膚的生長。 而且經過試驗，我們使用的中藥油膏與散劑對多種致病菌有很好的殺、抑菌作用（見表），內治結合外治、扶正祛邪^（8）；血糖過高，更應注意結合西醫快速降糖的治療^（9），中西醫結合才能及時控制血糖，從而有利於控制壞疽的惡化，獲糖尿病下肢壞疽較好的治療效果。

後附：

作者自製糊塗膏成分： 蒼朮，黃柏，延胡索，煅石膏，爐甘石。

References

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

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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

作者簡介:

鄭萍,教授，原上海第二醫科大學瑞金醫院,現美國加州波西亞診療中心