Thromboangiitis obliterans belongs to the gangrene category of traditional Chinese medicine, which is mostly caused by cold and dampness, trauma, blood stasis and other meridians blocking, so that qi and blood can not reach the limbs and the limbs lose the nourishment of qi and blood.

Western medicine believes that the main pathogenesis of this disease is non-suppurative inflammation of small and medium-sized arteries and veins, blocked blood circulation, loss of blood supply to limbs, leading to chills, numbness, pain, and even ulceration and necrosis of toes (fingers) and even limbs.

2. Understanding of gangrene by TCM in past dynasties.

As early as the Spring and Autumn Period and the Warring States Period, there was a detailed discussion on gangrene in Huangdi Neijing, saying that "cold evil can cause blood weeping in meridians, but blood weeping is not good." If it fails, the defensive qi will return to it, and the carbuncle will not swell. Cold turns into heat, heat is better than carrion, and carrion festers. Purulent diarrhea leads to rotten tendons, which leads to bone injury, and bone injury leads to bone marrow loss. No diarrhea due to bone emptiness. When the blood is dry and weak, the bones and muscles are not prosperous, and the meridians are leaking ... It is caused by the name of the foot, and its shape is red and black. "Huangfu Mi's Jin Acupuncture Classic changed carbuncle to gangrene, and the name of gangrene has been extended to this day.

Hua Tuo's Secret Biography of the Magical Doctor in the Han Dynasty said: "This disease occurs at the tip of the finger or toe, and it itches first and then hurts. Nails are black and will collapse after a long time. " And founded Simiao Yongan Decoction. So far, Simiao Yongan Decoction has a certain effect on gangrene.

Sun Simiao's "Thousands of Women's Wings" in the Tang Dynasty said: "Poison is cut in meat, and poison is cut in bone." The method of surgical debridement is put forward, which is basically consistent with the current method of nibbling debridement.

Chen Shigong's Authentic Surgery in the Ming Dynasty elaborated on gangrene in detail, saying: "Those who have gangrene on their husbands are rotten on the outside and bad on the inside ... Most people who suffer from this disease are born on their hands and feet ... Their pain is like fire-breathing soup, but their bones are fragile and their muscles are weak." Summarize the therapeutic principle of "harmonizing qi and blood, nourishing spleen and stomach … nourishing body fluid and strengthening kidney water". Establish effective prescriptions such as Jiedu Jisheng Decoction, Yinyang Erqi Dan, Qingshen Powder and other external treatments such as surgical debridement, moxibustion and external application. Enriched the content of syndrome differentiation treatment.

Xue Lizhai's words were quoted in the Ming Dynasty's "Full Moon Lifting". "This syndrome is caused by toxic accumulation because of frying thick wine noodles with paste, or because of careless labor and exhaustion of kidney water". He also said, "Covering dead meat is caused by refusing to camp gas because of poisonous gas. Condition, to Yin Qi and blood hard to reach ".

Gu Bu Tang, founded by Zou Wufeng in Qing Dynasty, still has certain guiding significance for the research and treatment of gangrene in the future.

In the Qing Dynasty, Qi Guangsheng's "Shucheng Quju" stated that "before unfolding, more than ten hairs were tied to the patient's fingers at the end of this section and tied for more than ten turns, gradually tightening it. Use toad venom, put it on the head of the original rice, and add moxibustion until the meat is boiled to death. The next day, when this part was completely dark, he found the seam of this part with a sharp knife and cut off Xu Shun's finger. If it's bleeding, stop it with a golden knife. The rest of the swelling is wrapped in a spindle. The next day, if there is still black gas, grind it with toad venom and mix it into a paste. The black gas fades and pus is self-generated. Use red and black paste to promote granulation growth and keep your mouth shut as usual. " These surgical methods still have reference value for removing necrotic tissue.

"Kangxi Dictionary" notes that "gangrene is the disharmony of the five internal organs, and the yin stagnates in the yang and produces gangrene."

After the founding of New China, the state set up research institutions for vasculitis in Chongqing and other places, conducted a lot of research and accumulated some experience.

3 Etiology and pathogenesis

Western medicine believes that

(1) Smoking, nicotine causes vasoconstriction. (2) Cold stimulation causes vasospasm. (3) Hormone level disorder, causing vasomotor disorder. (4) mold infection.

In addition, after years of observation, many patients had a history of trauma before the onset, some of them were injured several years ago, even more than 10 years ago. Therefore, it is considered that blood stasis and chronic persistent infection caused by trauma are also one of the reasons.

The above factors cause small and medium-sized arteriovenous spasm, non-suppurative inflammation, and increased blood viscosity, leading to thrombosis, even blood flow occlusion, and limb blood supply disorder, which is the main pathogenesis of vasculitis.

Chinese medicine believes that

(1) Cold-dampness invading collaterals. (2) Traumatic blood stasis and vein blockage. (3) Emotional disorder, qi stagnation and blood stasis.

The main pathogenesis of gangrene is that the above factors block the channels and collaterals, so that qi and blood can not run smoothly, and the limbs lose the warmth of qi and blood, leading to pain, ulceration and even necrosis.

My understanding

As Ren Laoyan said: "The pathology of phlegm and blood stasis is quite similar to thrombosis" (Ren Yingqiu Medical Collection). Vasculitis is similar to the theory of phlegm and blood stasis in traditional Chinese medicine because of its etiology, cold and dampness, trauma, vasospasm, and pathological symptoms such as thrombosis occlusion, numbness of affected limbs, pain and cyanosis.

Four symptoms

clinical picture

Thromboangitis obliterans is common in young men. The lesions mostly started from unilateral lower limbs, and gradually developed into bilateral ones, even involving upper limbs. According to the development of the lesion, it can be roughly divided into three stages.

The first stage of ischemia: the affected limb has chills and numbness, and the affected foot and calf are slightly sore. After a long walk, the calf aches and muscle cramps, forcing the patient to limp or sit down and rest. The pain can disappear after a short rest, and it can recur after walking for a period of time, that is, "intermittent claudication". Some patients have superficial phlebitis. The skin of the affected foot is slightly pale, and the pulsation of the dorsal artery and posterior tibial artery of the affected foot is weakened.

The second stage of malnutrition: the affected limb is cold and the pain is persistent, especially at night, which forces the patient to stay awake, bend his knees and hold his feet, or hang the affected limb to the end, and the pain can be slightly relieved. The skin of the affected limb is pale or red with blue-purple spots. The skin is dry and the toenails become thick and brittle. Muscle atrophy of calf. The pulse of dorsal foot artery and posterior tibial artery disappeared.

The third stage of tissue necrosis: the pain in the affected limb is more severe. Black toe (finger), gangrene, ulcer formation, and gradually spread to the whole toe (finger), and even to the ankle. If it is complicated with infection, it will become wet gangrene, with more severe pain and swollen limbs. When the infection is serious, there will be symptoms such as fever and chills.

Syndrome differentiation of TCM

Real evidence

Cold-dampness type: intermittent claudication, or numbness and pain in the affected limb, which will be relieved when it is warm and aggravated when it is cold. The skin of the affected foot is pale and cold to the touch. If it is cold, the pain is severe, the tongue is pale and blue, the coating is thin and white, and the pulse is tight. If it is very wet, the affected limb will suffer from heavy pain, fatigue, loss of appetite, thick and greasy tongue coating and slow pulse.

Type of wind phlegm and blood stasis: the affected limb is sore and numb, the skin is flushed, and it is not warm to touch, and ulcers and gangrene can be seen at the extremity. Accompanied by chest tightness, nausea, loss of appetite, fat tongue, greasy fur and slippery pulse.

Blood stasis type: the affected limb has persistent severe pain, while the rest has warm pain. The affected toe (finger) is purple or dark red, and the skin becomes thin, rough and cracked, and it feels cold. Gangrene or ulcer can be seen in limbs. Dark complexion, purple tongue or ecchymosis, ecchymosis and thready pulse.

Heat-toxic type: the affected limb has burning pain, swollen flush or dark red, which makes it feel burning when touched. The limbs are ulcerated and necrotic, with yellow and sticky pus, foul smell, dark red tongue, yellow greasy fur or yellow dryness. When heat toxin invades the viscera, it is accompanied by aversion to cold, fever, thirst and boredom.

Weak syndrome

Type of qi deficiency and blood stasis: limb pain, dark purple, thin and chapped skin, muscle atrophy, and tepid touch. Ulcer, gangrene, long-term nonunion, pus clearing. With emaciation and fatigue, his face is dark. The tongue is dark or lavender with thin coating and weak pulse.

Yang deficiency type: the affected limb is painful, cold, slightly warm and cold to the touch. Black limbs, ulcer gangrene, long-term nonunion. Accompanied by chills, cold limbs, aching waist and legs, pale mouth, loss of appetite, pale complexion, pale or purplish tongue, little moss, and weak pulse.

Spleen deficiency and dampness resistance type: the affected limb is heavy and painful, and the muscles are atrophied or swollen. There may be ulcers in the limbs that do not heal for a long time. Accompanied by fatigue, laziness, nausea, inadequate diet, or dizziness, pale tongue, white fur, slippery or greasy.

Type of deficiency of both yin and blood: the affected limb is painful, emaciated, and the limbs are dark red, with ulcers and gangrene, which will not heal for a long time. Dizziness, insomnia, fever, night sweats, dark red tongue tip and rapid pulse.

The above-mentioned syndrome types are summarized by my years of theoretical discussion and detailed observation of a large number of patients. However, when facing patients, the boundaries of each syndrome type are not necessarily clear, and sometimes several syndromes are mixed with each other. Therefore, clinical observation, careful analysis, careful syndrome differentiation, and flexible prescription and drug selection are necessary conditions for achieving satisfactory curative effect.

5 Chinese medicine treatment

According to relevant books and magazines, the traditional treatment methods are as follows:

Cold-dampness type: it is advisable to warm yang to dispel cold and remove dampness, and to add and subtract Yanghe decoction for cold and Duhuo Jisheng decoction for dampness.

Wind phlegm and blood stasis type: no data record. I used Pinellia ternata, Atractylodes macrocephala and Gastrodia elata.

Blood stasis type: it is appropriate to promote blood circulation and dredge collaterals, and use Xuefu Zhuyu Decoction and Taohong Siwu Decoction to add and subtract.

Heat-toxic type: it is advisable to clear away heat and detoxify, and use Simiao Yongan Decoction and Gubu Decoction to add and subtract.

Qi deficiency and blood stasis type: there is no data record, and I use Buyang Huanwu Decoction to add and subtract.

Yang deficiency type: it is advisable to warm kidney and help yang, and use Jinkui Shenqi Decoction and Gui You Pill to add and subtract.

Spleen deficiency and dampness blocking phlegm resistance: no data record. I use Liujunzi Decoction Simiao Powder to add and subtract effectively.

Deficiency of both yin and blood: it is advisable to nourish yin and blood, and add and subtract Liuwei Dihuang Decoction and Siwu Decoction.

In addition, the ulcer surface can be externally applied with Qufu Shengji ointment, and the necrotic tissue can be removed by nibbling therapy.

6 medical care

Because vasculitis is more related to moisture, freezing, trauma, smoking and other factors, patients should always pay attention to moistureproof, antifreeze, trauma prevention and quit smoking and drinking.

7 case introduction

Medical record 1, Chang, male, 42 years old, saw a doctor on April 13, 2007.

Three years ago, the patient gradually felt pain in the right lower limb, followed by wandering cords and swelling and pain in both lower limbs. He was diagnosed as "thromboangiitis obliterans" in many hospitals. After many treatments, the situation has improved. Since it rained in August last year, the pain in the right lower limb has become more and more severe, and many treatments have failed. I came to see the doctor today. Self-reported chills and persistent pain in the right lower limb, especially in the foot, with severe pain, especially at night, making it difficult to sleep. With fatigue.

Examination: The right calf is slightly blue, the right foot is dark, the toenails are thin, rough and brittle, the affected foot is tender and cold, and the pulse of dorsal foot artery and posterior tibial artery disappears.

The tongue is purple, the coating is thin and the pulse is astringent.

Traditional Chinese medicine diagnosis: gangrene, dampness and blood stasis syndrome.

It is advisable to remove dampness, blood stasis and collaterals.

Mix thrombolytic Tongmai powder 1 with No.4 300g evenly, and take it with warm boiled water in the morning and evening 10g. Take 1 a month.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

The second diagnosis from May 65438 to May 5, 2007 showed that the foot pain was slightly relieved and the color was improved. The original prescription is taken for two months.

On July 22, 2007, the affected limb became warmer, the pain in the calf disappeared and the color returned to normal. My foot pain has basically disappeared, so I can sleep peacefully at night. There is still pain when catching a cold or exercising, and the color basically returns to normal.

The original prescription recovered after taking it for one month.

Medical record 2, Liu, female, 38 years old, saw a doctor on May 65438+5, 2007.

In the past three years, the patient has gradually felt tired and weak in both legs and pain in his left calf when walking. In the past four months, he gradually felt cold and pain in his left big toe. He was diagnosed as "thromboangiitis obliterans" in several hospitals, but the treatment was ineffective and the pain gradually increased. I report that my left foot is cold and painful, especially my big toe, which hurts more at night and makes it difficult to sleep. The limbs are heavy and weak, and the appetite is poor.

Examination: The skin of the left foot is flushed and the big toe is slightly blue. Dorsal artery of foot and posterior tibial artery were not touched.

The tongue is purplish, greasy with fur, and the pulse is moist.

Traditional Chinese medicine diagnosis: gangrene, cold-dampness syndrome.

It is advisable to warm yang and eliminate dampness.

The prescription is thrombolytic Tongmai powder 1 600g, morning and evening 10g, taken with warm water. Take 1 a month.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

June 2007 15, foot pain relieved. Food intake has increased. The original party took it for another month.

On July 22, 2007, the patient's foot became warmer, the color basically returned to normal, the pain disappeared during rest, and the big toe still felt pain when walking.

The original prescription was cured after another month.

Medical record 3: Deng Mou, female, 48 years old, saw a doctor on May 2, 20071.

The patient suffered from varicose veins of both lower limbs for nearly 20 years. At the beginning of this year, due to wet and cold, my condition gradually worsened, and I gradually felt pain, heaviness and swelling in my calf.

Examination: The veins on the inner and rear sides of both legs are worm-shaped, with rapid swelling, a few lumps and strips, tenderness, mild purple swelling of both legs and severe swelling of ankles.

Accompanied by fatigue, improper diet, pale purple tongue, greasy fur and astringent pulse.

Diagnosis: varicose veins of both lower limbs complicated with phlebitis.

Syndrome differentiation: stagnation of cold and dampness and poor blood circulation.

It is appropriate to treat dampness, dispel cold and dredge pulse.

The prescription is thrombolytic Tongmai powder 1 600 g, morning and evening 10g, Jisheng Shenqi Pill 1 in the morning and evening, taken in warm water for one month.

Description: Wear long elastic socks to prevent moisture, raise the lower limbs and lie flat, and avoid eating cold and irritating food.

After taking 1 month, the pain in the affected limb basically disappeared. After another course of treatment, the pain and swelling of both lower limbs disappeared, the color returned to normal, the lumps and hard strips basically disappeared, the varicose veins were relieved, the lumps became smaller, and the mental appetite improved.

Medical record 4, Wang, male, 6 1 year old, saw a doctor on June 9, 2007.

The patient has varicose veins of both lower limbs for nearly 30 years, and his condition has repeatedly failed to heal. This year, my situation is getting worse. I gradually feel pain in my calf, my skin thickens, and I have a small rash, which is unbearable.

Examination: The veins on the inside and back sides of the legs are lumbricus-shaped, wrapped quickly, and are hard and tender when touched. The legs are slightly purple and swollen, the skin is rough, there are bumps the size of rice grains, and there are a small amount of exudates and scratches.

The tongue is pale and purplish, the coating is thin and white, and the pulse is fine and astringent.

Diagnosis: varicose veins of both lower limbs with phlebitis and eczema.

Syndrome Differentiation: Dampness blocks blood stasis.

The prescription is thrombolytic Tongmai powder 1 300g, No.4 300g, mixed evenly, 10g in the morning and evening, taken with warm water. Take 1 a month.

Another prescription:

Cimicifuga 6g Radix Puerariae 10g Radix Paeoniae Alba 8g Radix Paeoniae Rubra 8g Radix Rehmanniae 25g

Schizonepeta tenuifolia 8g Saposhnikovia root 8g Dictamni bark 8g Kochia scoparia 8g Glycyrrhiza 6g

Daily 1 dose, decocted in water.

Description: Wear long elastic socks to prevent moisture, raise the lower limbs to lie flat, avoid cold and irritating diet, and try to avoid scratching the affected limbs.

After 20 days, the itching of both lower limbs disappeared and the papules subsided. Stop taking the decoction, and then take the thrombolytic Tongmai powder 1 No.4 and No.4 as before.

In July 2007 10, the pain and swelling of both lower limbs were greatly reduced.

One month after the original prescription, the pain and swelling of the affected limb disappeared, the skin color basically returned to normal, the lumps and strips basically disappeared, and the varicose veins were alleviated.

Continued (20 10 65438+2 February)

Medical record 1, Wang, male, 3 1 year old, saw a doctor on October 22nd, 2009.

In the past two years, the patient gradually developed intermittent claudication in his right leg, and then gradually felt pain and chills in his right foot. He has been diagnosed as "thromboangiitis obliterans" in Lanzhou, Xi 'an and other hospitals, and has not improved after various treatments. It has become more and more serious in the past six months, and the little toe of the right foot has gradually festered.

Obviously, my right foot is cold and painful, especially at night, and I can't sleep.

Examination: the muscles of the right lower limb are atrophied, the skin is pale, the right foot is blue and purple, and it feels cold. The little toe festers with a small amount of pus clearing.

The tongue is slightly blue and the moss is thin and white. The pulse is thin and astringent

Traditional Chinese medicine diagnosis: gangrene, cold coagulation and blood stasis syndrome.

Treatment should be warming yang and dispelling cold, promoting blood circulation and removing blood stasis.

Choose thrombolytic Tongmai powder No.3 600g, morning and evening 10g, warm boiled water to take, January 1 as a course of treatment.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

From June 5438 to February 24, 2009, when the patient was diagnosed for the second time, the foot pain was slightly relieved, cyanosis basically subsided, the ulcer surface was reduced, and pus disappeared. The original party took it for another month.

1October 20 10-65438+25 After three visits, the affected foot became warmer, the pain disappeared at rest, and it felt a little pain when walking, the color basically returned to normal, and the ulcerated surface healed.

Thrombolytic Tongmai Powder No.5 will be cured if the former method is taken for two months.

The recent follow-up was normal.

Medical record 2: Lian Mou, female, 42 years old, saw a doctor on 2065 438+00- 10-5.

In the past six months, the patient gradually felt pain in his left calf while walking, and then his left foot was painful and cold. The patient doesn't mind, but his condition is getting worse. The pain has obviously increased recently.

Examination: the left lower limb is slightly swollen and blue, especially the left foot. My left foot feels cold.

The tongue is slightly blue and the coating is white and thick. The pulse is astringent.

Traditional Chinese medicine diagnosis: gangrene, cold-dampness syndrome.

Treatment should dispel cold and remove dampness.

Choose thrombolytic Tongmai powder 1 600g, morning and evening 10g, and take it in warm water, and January 1 is a course of treatment.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

2065 438+00. 2. 8 The foot pain was slightly relieved, and the swelling and cyanosis basically subsided. The original party took it for another month.

20 10, 12, the patient's limb claudication basically disappeared, the foot became warmer, the pain disappeared at rest, there was a little pain when walking, and the color basically returned to normal.

The former method lasted for more than a month and was cured.

The recent follow-up was normal.

Medical record 3: Yang, male, 38 years old, saw a doctor on 2065 438+00- 10-22.

The patient has a history of frostbite on his left foot. In the past two years, he gradually felt pain in his left foot, which aggravated when walking. He was diagnosed as "thromboangiitis obliterans" in a hospital in Lanzhou. After treatment, there are light and heavy. In the past two months, the pain has gradually increased and it is cold. The joint of toe 1 and toe 2 is gradually festering. Many treatments failed, and the condition became more and more serious.

Self-reported persistent severe pain in the left foot, especially in the toes, aggravated by cold, painful at night, and difficult to sleep.

Examination: The left foot is bruised and the toenails are thick and brittle. The toe joints of toe 1 and toe 2 are ulcerated. The left foot is tender and cold, and the pulse of the dorsal artery of the foot disappears.

The tongue is blue and purple, and the pulse is astringent.

Traditional Chinese medicine diagnosis: gangrene, cold coagulation and blood stasis syndrome.

Treatment should be warming yang and dispelling cold, promoting blood circulation and removing blood stasis.

Choose thrombolytic Tongmai powder No.3 600g, morning and evening 10g, warm boiled water to take, January 1 as a course of treatment.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

The second diagnosis on February 26th, 20 10 showed that the foot pain was slightly relieved, the congestion and swelling subsided slightly, and the ulcer surface was reduced. The original party took it for another month.

March 3 10, 3 1, 2065438, 365438, 3 1, 365438, 365438.

Thrombolytic Tongmai Powder No.5, 10g, taken in the morning and evening, respectively, for one month.

After seeing a doctor for four times on 20 1 May1day, the pain of the affected foot disappeared at rest, but there was still a little pain when walking, the color of the affected foot basically returned to normal, and the ulcerated surface healed.

Thrombolytic Tongmai Powder No.5 was taken again for one month and recovered.

The recent follow-up was normal.

Medical record 4: Liu, male, 39 years old, saw a doctor on March 22, 2065438+00.

The patient suffered from thromboangiitis obliterans for more than 10 years. Originated from the right lower limb and then involved the left lower limb. I have been treated in many hospitals, and I will get better from time to time, but I can't heal again and again. In recent two years, the pain has become more and more severe, and the fourth and fifth toes on the right side have gradually festered and died.

Self-reported chills and persistent pain in both lower limbs, especially in the fourth and fifth toes of the right foot, with severe pain, especially at night, making it difficult to sleep.

Examination: the lower limbs are blue, the muscles are atrophied, the hair falls off, the feet are purple and black, and the toenails are thin, rough and fragile. The right foot is worse, and the fourth and fifth toes are ulcerated and necrotic, with a small amount of pus clearing. Feet are tender and cold, and the pulse of dorsal foot artery and posterior tibial artery disappears.

Accompanied by emaciation, listlessness and loss of appetite.

The tongue is purple, the coating is thin, and the pulse is fine and astringent.

Traditional Chinese medicine diagnosis: gangrene, qi deficiency and blood stasis syndrome.

Treatment should be invigorating qi and promoting blood circulation, removing blood stasis and dredging collaterals.

Choose thrombolytic Tongmai powder No.5, morning and evening 10g, and take it with warm water. February 1.

Tell me to quit smoking and drinking, avoid cold and dampness and prevent trauma.

20 10 On May 26th, the pain in both lower limbs was slightly relieved, and I could fall asleep at night. The fourth toe on the right side was ulcerated and necrotic as before, and the pus basically disappeared. The original prescription was prescribed again in February.

At the third visit on August 2, 2065438+00, the lower limbs basically warmed up, the pain in the lower legs basically disappeared, the cyanosis basically subsided, and the hair gradually grew. The pain in your feet is still obvious when you are cold or active. The 4th and 5th toes on the right side fall off, and the falling surface is scabbed.

After taking the original prescription for two months, all the symptoms disappeared and the mental appetite basically improved. The exfoliated surfaces of the right fourth and fifth toes healed.

The recent follow-up was normal.

In addition, appropriate use of antibiotics.

But this can only be used for reference, and the treatment must be treated by Chinese medicine.