2 Summarize carbuncle as the disease name [1]. "Naoshu carbuncle in Huangdi Neijing": "It originated on the toes, and the name was except carbuncle. Its shape is red and black, and it won't die. If it is not red and black, it will not die. If you are anxious, you will die. " That's gangrene [1].
Gangrene is the name of this disease [2][3]. Out of the "Liu Ghost Legacy" Volume 4 [2]. Also known as osteonecrosis, carbuncle, carbuncle, gangrene, nail gangrene and furuncle [2]. Refers to the chronic peripheral vascular disease that occurs at the extremities, with local pain and necrosis, and severe toe (finger) joint necrosis and shedding [4]. Most of them are on the toes, and the toes will fall off if they collapse for a long time, hence the name gangrene [2]. Its clinical feature is that it occurs at the ends of limbs, especially lower limbs. At first, I was afraid of the cold, pale and numb, and limped intermittently, then I had severe pain and long-term toe injury. Necrosis turns black, and even the toe (finger) joint falls off. Common in young men or the elderly. North China is more common than South China.
There is a record of this disease in Huangdi Neijing Lingshu carbuncle, which says: "It is caused by the toe, and the name is off carbuncle, and it is red and black, which is to cure death; Not red and black, not death. Cured, anxious. "
Fallout is equivalent to thromboangiitis obliterans and atherosclerosis obliterans in western medicine [2].
3 etiology and pathogenesis of abscess abscess is mostly due to the strong smell of alcohol and tobacco, which leads to the stagnation of fire poison in viscera and the loss of kidney yin, which can not control fire; Or due to exogenous cold and dampness, toxic evil, disharmony between ying and Wei, and impassability of meridians, it will become hot for a long time and stagnate qi and blood [2]. Thromboangiitis obliterans and diabetic gangrene in modern medicine are similar to this disease [5].
Absence of carbuncle is mainly due to unhealthy temper, deficiency of kidney yang and invasion of cold and dampness. Poor temper, insufficient metaplasia, insufficient qi and blood, can not nourish viscera; You can't nourish your limbs outside. Yang Qi deficiency of spleen and kidney can't warm limbs, and if you suffer from cold and dampness again, your blood will stagnate, your meridians will be blocked, and your pain will be unbearable. If they are not nourished, their bodies will wither and fall off. If the cold pathogen persists for a long time, it will be depressed and turn into heat, and if the toes (fingers) are immersed in damp heat, they will be red, swollen and purulent. Heat-evil can damage yin, and long-term illness can lead to deficiency of yin and blood, limb dystrophy, dryness and atrophy.
The occurrence of carbuncle is related to factors such as long-term smoking and trauma.
In a word, gangrene is based on deficiency of both spleen and kidney, marked by cold-dampness trauma, and characterized by stagnation of qi and blood and obstruction of meridians.
4 Symptoms of Abscess "Authentic Surgery" said: "Those who get rid of gangrene are rotten outside and rotten inside ... their bones are dry and stiff, their stench is difficult to distinguish, and their lives are difficult to treat."
The onset of carbuncle is slow. At first, it suffered from white hair and numbness, and the pain disappeared after walking and stopping to rest, showing intermittent claudication [2][5]. The pain lasts for a long time, and the skin on the instep gradually turns purple and dark, and the affected toe turns dark and dark from red to ripe red dates. Finally, the toe festers and rots, and the pain is severe. The toe necrosis falls off and spreads to the instep and calf, and the wound is difficult to close [5][2]. Even five failures and so on [2]. Necrosis is a necrotizing disease of toes, which mostly occurs in lower limbs [5].
The diagnosis of carbuncle thromboangiitis obliterans mostly occurs in cold season, especially in men aged 20 ~ 40; Often involve one lower limb first, then the opposite side, and a few patients may involve the upper limb; Most patients have a history of cold, dampness, smoking and trauma. Atherosclerosis obliterans mostly occurs in the elderly (over 50 years old).
5. 1 stage According to the disease development process, the clinic is divided into three stages:
In the first stage (ischemic stage), the extremities of the affected limbs are cold, afraid of cold, numb, sore and intermittent claudication. After walking 500- 1000 m, the affected limb feels pain in the calf or sole and limps. After a short rest, the symptoms eased or disappeared. When walking the same or shorter distance, the affected limb will feel sore. With the aggravation of the disease, the walking distance is getting shorter and shorter. Mild muscular atrophy, dry skin, gray skin, skin temperature slightly lower than the healthy side, the pulse of dorsal artery of foot weakened, and some patients had wandering red hard rope (superficial thrombophlebitis) in their calves.
In the second stage (malnutrition stage), the affected limbs are cold, cold-averse, numb, sore, intermittent claudication is aggravated, there is resting pain, and it is very painful at night, which makes it difficult for people to fall asleep: patients often sit with their knees folded. The muscles of the affected foot are obviously atrophied, the skin is dry, the hair falls off, the toenails are thickened, the growth is slow, the skin is pale or flushed or purple, and the pulse of the dorsal artery of the affected foot disappears.
The third stage (necrosis stage) is further aggravated in the second stage, and the toes are swollen, ulcerated and necrotic, or the toes are black and dry, showing lower gangrene. Gangrene can start from one toe or several toes and gradually develop upwards. When complicated with infection, it is obviously red and swollen, with severe pain in the feet and fever all over the body. After active treatment, the redness and swelling of the affected foot can subside, the ulcer can heal and gangrene is limited. If gangrene occurs above the instep, the swelling and pain are difficult to control and the course of disease is long. The patient may be tired, weak, unwilling to eat, dry mouth, emaciated and even faint.
5.2 Classification According to the range of limb necrosis, gangrene can be divided into three grades: the first grade gangrene is confined to toes or fingers, the second grade gangrene is confined to the plantar part, and the third grade gangrene develops to the ankle joint and above.
5.3 Gangrene has a slow prognosis and a long course of disease, which is often aggravated in cold season and can recur after being cured.
5.4 Auxiliary examination of limb ultrasound, hemogram, nail fold microcirculation, arteriography, blood lipid and blood sugar can make a definite diagnosis, which is helpful for differential diagnosis and understanding the severity of the disease.
6 Diseases that need to be differentiated from gangrene 6. 1 Patients with diabetic gangrene have symptoms such as diabetes, polydipsia and polyuria. Positive urine sugar, elevated blood sugar, moist local gangrene, rapid development and wide range. If the inflammation is not controlled in time, it will easily lead to the invagination of toxic pathogens.
6.2 Raynaud's disease (limb arterial spasm) is more common in young women. Upper limbs are more common than lower limbs, and hands are more common. Every time due to cold and spirit, the hands appear cold and pale, then cyanosis and flushing, and finally return to normal trichromatic changes (Raynaud's syndrome). The arterial pulse of the affected limb is normal, and there is generally no gangrene of the limb.
7 Treatment of carbuncle 7. 1 Syndrome differentiation and treatment focuses on nourishing kidney and enriching blood, invigorating spleen and benefiting qi, and promoting blood circulation and detoxification [2]. You can choose to take Jiedu Jisheng Decoction, Yanghe Decoction, Gubu Decoction, Simiao Yongan Decoction and Ginseng Yang Rong Decoction. [2].
7. 1. 1 gangrene of cold and dampness blocking collaterals refers to cold and dampness blocking collaterals, toes (fingers) like warm and cold, pale and cold, numb and painful, suffering from cold pain, walking is unfavorable, the pain is aggravated when walking more, and the pain is relieved after taking a rest.
7. 1. 1. 1 Symptoms The affected toes (fingers) are warm and cold, numb and sore, and the pain is aggravated when walking more, and the pain is relieved after a short rest, with pale skin, cold touch and weakened yang pulse; The tongue is pale, the coating is white and greasy, and the pulse is heavy and thin.
7. 1.65438+ cold and dampness block collaterals, and Yang can't reach the end of the four seasons, so he will be numb and sour, and he will be cold when he touches it; Internal resistance of cold and dampness, bad qi and blood, more stagnation of qi and blood when walking, and aggravated pain; When cold and dampness block collaterals, the pulse of falling yang weakens; Pale tongue, white greasy fur and deep and thin pulse are signs of yang deficiency and cold excess.
7. 1. 1.3 treatment: warming yang to dispel cold, promoting blood circulation and dredging collaterals.
7. 1. 1.4 prescription of Yanghe decoction.
7. 1.2 gangrene of qi stagnation and blood stasis refers to blood stasis, which is manifested as toe pain, heavy walking and difficulty in moving, and the skin color of the affected toe changes from pale to dark red, which is aggravated when drooping and pale when lifting. There may be wandering erythema, nodules or hard cords in the calf, and the pain continues to increase, so that you can't sleep all night. Dark red tongue or ecchymosis, white tongue coating, string or astringent pulse, and disappearance of yang pulse are common symptoms of gangrene [4].
7. 1.2. 1 Symptoms: the pain in the toe (finger) is aggravated, it is difficult to sleep at night, and the gait is difficult. The skin of toes (fingers) is dark red or purple, and the drooping is more severe. The skin is cold and dry, the muscles atrophy, and the yang pulse disappears. The tongue is dark red or ecchymosis, with thin white fur and astringent pulse.
7. 1.2.2 Dialectical analysis, stagnation of cold pathogen, stagnation of yang, stagnation of qi and blood, and sore limbs; At night, the yang is turned off, so the pain is aggravated; Qi and blood stasis, limb dystrophy, it is difficult to walk, dry and cold skin, muscle atrophy; Qi and blood stagnate in the pulse, and yang pulse disappears; Blood stasis, dark red or purplish red toe skin, dark red tongue or ecchymosis; Chord pulse governs pain, while astringent pulse governs blood stasis.
7. 1.2.3 treatment: promoting blood circulation and removing blood stasis, dredging collaterals and relieving pain.
7. 1.2.4 Prescription for the treatment of Taohong Siwu decoction with pangolin, earthworm, frankincense and myrrh.
7. 1.3 gangrene with toxic damp-heat refers to toxic damp-heat, severe pain in the affected limb, light day and heavy night, aversion to cold and heat, purple and dark local skin color, swelling, progressive purple-black, infiltration and spread, ulceration and corruption, bad breath, dull flesh color on the wound surface, and even spread from toe to toe.
7. 1.3. 1 Symptoms: the affected limb has severe pain, light day and heavy night, local swelling, dark purple skin, immersion and spread, ulceration and decay, and bright flesh color; Body heat, dry mouth, constipation and red face; Red tongue, yellow greasy fur and thready pulse.
7. 1.3.2 Dialectical analysis shows that if qi and blood stagnate for a long time, it will turn into heat, or damp heat will invade the affected limb, and the affected limb will have severe pain, local swelling, purple skin color, water immersion and spread, ulceration and decay, and the flesh color will not be fresh; When the heat is excessive and the yin is injured, the body is dry and hot, and constipation is red; Red tongue, yellow greasy fur and rapid pulse are the signs of damp-heat toxin.
7. 1.3.3 treatment: clearing away heat and promoting diuresis, promoting blood circulation and removing blood stasis.
7. 1.3.4 The prescription is Simiao Yong 'an Decoction plus Fructus Forsythiae, Cortex Phellodendri, Semen Phaseoli, Radix Salviae Miltiorrhizae, Rhizoma Chuanxiong, Radix Paeoniae Rubra, Radix Achyranthis Bidentatae, etc.
7. 1.4 gangrene of yin injury caused by heat toxicity refers to the common symptoms of yin injury caused by heat toxicity, such as dry skin, hair loss, nail thickening and deformation, muscle atrophy, gangrene of toe (finger), red tongue, yellow tongue coating and thready pulse.
7. 1.4. 1 Symptoms: dry skin, hair loss, thickening and deformation of nails, muscle atrophy, gangrene of toes (fingers); Dry mouth and thirst, constipation and redness; Red tongue, yellow fur, thin and thin pulse.
7. 1.4.2 Dialectical analysis: If pathogenic factors persist for a long time and turn into heat, heat and toxin will damage yin, and yin deficiency will lead to malnutrition, then skin will be dry, hair will fall off, toenails will be thickened and deformed, and muscles will atrophy; If the body is full of toxic heat and yin deficiency, the toe (finger) will be gangrenous; Yin deficiency causes dry mouth and thirst, constipation and redness; Red tongue, yellow fur and thin pulse are all manifestations of yin deficiency and internal heat.
7. 1.4.3 treatment: clearing away heat and toxic materials, nourishing yin and promoting blood circulation.
7. 1.4.4 Prescription treatment of bone tonic soup.
7. 1.5 gangrene with deficiency of qi and blood refers to gangrene with deficiency of qi and blood, which is characterized by haggard face, emaciation, listlessness, long-term unhealed sore surface after necrotic tissue falls off, dark or reddish granulation, pale and fat tongue and weak pulse [4].
7. 1.5. 1 The course of symptoms is prolonged, the wound surface does not heal for a long time after the necrotic tissue falls off, and the granulation is dark red or light but not fresh; Burnout and fatigue, no desire to eat, pale face, thin body; The tongue is pale, with little coating, and the pulse is thin and weak.
7. 1.5.2 Dialectical analysis shows that if the disease persists for a long time, both qi and blood are deficient, the limbs are malnourished, the wound is not healed for a long time, the flesh color is not fresh, and the body is thin; Deficiency of qi and blood leads to fatigue; Spleen deficiency, you don't want to eat; Pale tongue, less fur and weak pulse are signs of deficiency of both qi and blood.
7. 1.5.3 therapeutic methods for invigorating qi and blood.
7. 1.5.4 bazhen decoction prescription.
7.2 External treatment of early gangrene should be separated by ginger moxibustion, with Coicis Semen boiled and hibiscus leaves each 15g, and mashed to relieve pain, or with aconite root, dried ginger and Evodia rutaecarpa. If the rot is black and the pain is unbearable, it is advisable to grind licorice into fine powder and thicken the sesame oil, and change it every day without interruption; After rotting, apply Shengji Yuhong ointment and Shengji powder; If black necrosis occurs, it should be surgically removed [2].
In the non-ulceration period, Chonghe ointment and Kurenai Rin Dan ointment can be used externally; You can also use Angelica sinensis 15g, Radix Angelicae Pubescentis 30g, Ramulus Mori 30g, and Radix Clematidis 30g, decocted in water, smoked and washed once a day/kloc-0; Or grinding Radix Aconiti Lateralis Preparata, Rhizoma Zingiberis Recens, Fructus Evodiae, etc. into powder, mixing with honey, and applying it to Yongquan point of the affected foot, changing the dressing 65,438+/-0 times a day, and stopping using it in case of drug eruption; You can also rub the back and calf of the affected limb with a little Kurenai Rin wine for 20 minutes each time, twice a day.
If the ulcerated ulcer area is small, it can be fumigated and washed with traditional Chinese medicine, and then externally applied with Shengji Yuhong ointment. If the ulcer area is large and the necrotic tissue is difficult to fall off, borneol zinc oxide oil (borneol 2g, zinc oxide oil 98g) can be used to soften the hard scab skin of the wound, and then the necrotic scab skin is removed in turn according to the degree of looseness, then the soft tissue is removed, and then the rotten bone is removed. Thorough debridement can only be performed after the inflammation has completely subsided.
7.3 Surgical treatment 7.3. 1 Necrotic tissue resection The boundary between necrotic tissue and healthy tissue is clear. After the proximal inflammation is controlled, it is feasible to resect necrotic tissue, and the bone section should be slightly shorter than the soft tissue section.
7.3.2 Excision and suture of necrotic tissue: The boundary between necrotic tissue and normal tissue is clear, proximal inflammation is controlled, and blood supply is improved. It should be divided into proximal incision, toe (finger) excision and suture or half toe excision and suture.
7.3.3 Amputation When necrosis spreads to the dorsum of foot and ankle, leg amputation is feasible, and if gangrene develops above ankle, knee amputation is feasible.
7.3.4 When the ulcer surface of skin grafting is large, skin grafting can be carried out after the wound surface is cleaned and the blood supply is improved.
7.4 Degeneration of integrated traditional Chinese and western medicine is equivalent to thromboangiitis obliterans and atherosclerosis obliterans in western medicine [2]. The diagnosis and treatment of integrated traditional Chinese and western medicine can be divided into four types: cold coagulation and blood stasis, qi stagnation and blood stasis, yin deficiency and heat toxicity, and deficiency of both qi and blood [2]. In treatment, on the basis of established prescription classification and multi-use, treatment based on syndrome differentiation according to the condition has improved the curative effect [2].
7.5 Acupuncture treatment Note: Acupuncture treatment is mainly used when gangrenous limbs do not collapse [5]. For patients with advanced ulcers, surgery is needed [5]. During the treatment, pay attention to keep the affected limb warm, prevent trauma and cooperate with appropriate exercise [5].
7.5. 1 Body acupuncture takes Zusanli, Yanglingquan, Sanyinjiao, Chengshan, Quchi, Hegu, Neiguan and Shoufen, taking 2-4 points at a time. Alternate every day 1 time.
Those with qi stagnation and blood stasis in junior middle school can choose Shu Ge, Guanyuanyu, Qihai, Zusanli, Sanyinjiao, Shangqiu, Xu Qiu and Zhao Hai [5]. Patients with sick hands are added with eight evils in neck 6 ~ chest 3; Lumbar 1 ~ lumbar 3 and eight winds are added to patients with podiatry [5]. Those with deficiency of both qi and yin in the later period can choose Guanyuan, Taixi, Zusanli, Taiyuan, Xue Hai and Shaofu [5].
7.5.2 Moxibustion method: Moxibustion with moxa sticks lasts for about 20 minutes, 1 ~ 2 times/day [5].
7.5.3 Ear acupuncture is used to remove the corresponding acupoints of foot tip, kidney, screen room, lower screen tip, brain, heart, liver and limbs [5]. Choose 2 ~ 3 points at a time, strong [5]. 0.2 ml of 0.5% procaine can also be used to block acupoints such as the lower foot end and the lower sieve tip [5].
7.5.4 Inject 0.5ml of 5% Angelica Injection into Xinshu, Shu Ge, Yanglingquan, Sanyinjiao and Xuanzhong points at 2-3 o'clock each time, daily 1 time [5].
7.6 Treatment of Severe Pain The main symptom of gangrene is pain, and in severe cases, it hurts and even keeps you awake all night. Therefore, effective analgesic treatment has become an important measure to treat gangrene. In addition to using analgesic drugs such as Demerol, you can also choose the following analgesic methods.
(1) 2.5 ~ 5mg of Ma Zhong (or ⅱ2 ~ 3mg of Ma Zhong Ⅱ) and 2.5 ~ 5 mg of chlorpromazine were added to the anesthesia of traditional Chinese medicine, and 20mL of normal saline was slowly injected intravenously at 9 o'clock in the evening to make the patients fall asleep for 6 ~ 8 hours, and used every 2 ~ 3 days 1 time. During the treatment, the patient should lie on his back, head side, and remove the pillow. Close observation and nursing should be carried out after operation.
(2) Continuous epidural anesthesia in the ward, conventional low-level epidural anesthesia, preferably only anesthetizing the affected limb, can last for 2-3 days, which can eliminate the pain and improve the swelling of the affected limb, and has a good effect on improving the general situation and performing surgery.
7.7 Take Ilex pubescens (the root of Erigeron breviscapus) 1 00 ~ 200 g with 400mL of water every day and take it orally twice.
(2) Inject compound Danshen injection 2-4 ml 1-2 times a day 1 time; Or add 20 ml of compound Danshen injection into 500 ml 10% glucose solution, intravenously drip/kloc-0 once a day for 2-4 weeks 1 course of treatment. ;
8. Daily health care for carbuncle patients 1. No smoking, eat less spicy and alcoholic products.
2. Work outdoors in winter, keep warm, have spacious and comfortable shoes and socks, and wash your feet with warm water every day.
3. avoid trauma.
4. The movement of the affected limb can promote the collateral circulation of the affected limb. The method is that the patient lies on his back, raises his lower limbs for 20-30 minutes, then his feet droop along the bed for 4-5 minutes, and at the same time, his feet and toes move down, up, inside and outside 10 times, and then his lower limbs lie flat for 4-5 minutes and exercise three times a day. It is forbidden when gangrene is infected.
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