Etiology and pathogenesis
Blockage of the collateral by phlegm and blood stasis due to dysfunction of the spleen:
Irregular food intake or indulgence in sweet and greasy food causes dysfunction of the spleen and stomach in transportation and transformation, and retention of damp and turbid fluid, resulting in blockage of the collaterals by phlegm-damp. Damp is characterized by flowing downward, it disturbs the circulation of qi and blood in the lower extremities to deprive the limbs of nourishment, and gangrene thus appears.
Retention of cold in the tendon and meridian due to yang deficiency of the spleen and kidney.
In persistent diabetes, yin influences yang resulting in deficiency of both yin and yang. Yang deficiency produces cold, cold freezes the tendons and meridians, and congeals blood; blood stasis blocks the collaterals to deprive the limbs of nourishment, and gangrene thus appears.
Excessive heat and rotted flesh due to downward flow of damp-heat:
Persistent diabetes causes deficiency of both spleen and stomach. Endogenously, deficiency of spleen qi leads to abnormal transportation and transformation of water, resulting in accumulation of damp; long-term retention of damp may turn into heat and toxin; exogenously, weakness of the spleen and kidney fail to fight against the invasion of exogenous pathogenic factors, damp-heat takes chance to enter the body. Endogenous damp-heat and exogenous damp-heat flow downward together to the foot and corrode tendons and flesh there, and gangrene thus appears.
In short, at the early stage, persistent diabetes consumes qi and blood, resulting in weakness of Yingqi (nutrient qi) and Weiqi (defensive qi), i.e. "Persistent disease would transmit deeply into the body and make the circulation of Yingqi ( nutrient qi ) and Weiqi ( defensive qi ) hesitant." The circulation of blood becomes unsmooth because of deficiency of qi and blood. Or persistent diabetes causes dysfunction of the spleen in transportation and transformation; damp accumulates into phlegm, phlegm-damp blocks the meridians and collaterals, the circulations of qi and blood are obstructed resulting in blockage of the meridians by blood stasis. Where there is obstruction, there is pain. The obstruction causes numbness, aching of limbs, dark red or blue purple foot. Along with the aggravation of disease, yang qi is more consumed, and antipathogenic qi is damaged. Deficiency of qi and blood fails to nourish blood vessels, and blood flow in the lower extremity becomes slow, manifesting cold pain worse at night. Since yang qi is deficient, toxin sinks to cause ulcer with erosion, which usually lasts for long time; or phlegm-damp due to spleen deficiency often turns into heat, and toxic heat accumulates into gangrene. "Excessive heat rots flesh, and rotted flesh may turn into pus", red, swollen and warm foot, or even ulceration and erosion with yellow sticky exudates would appear. Deficiency of the spleen and kidney is Ben (root of disease); blood stasis, turbid phlegm and damp-heat are Biao (manifestation of disease). The disease is a syndrome of Ben (root of disease) deficiency and Biao (manifestation of disease) excess.
Identifying the location of disease
Diabetic foot is resulted form diabetes, the location of disease is mainly in the spleen and kidney, but the intensity of spleen deficiency and kidney decline varies according to the feature of syndrome. Generally speaking, at the early stage, the pathogenic factors are located in the meridians and collaterals, because persistent diabetes leads to insufficiency of blood due to spleen deficiency, which causes weakness of Yingqi (nutrient qi) and Weiqi (defensive qi); at the later stage, the pathogenic factors are located in the tendons and vessels, because yang qi is consumed, kidney yang is deficient, cold is retained in blood vessels and both qi and blood are insufficient.
Distinguishing Biao (manifestation of disease) and Ben (root of disease)
Deficiency of the spleen and kidney is Ben (root of disease) of the disease; blood stasis, turbid toxin and damp-heat are Biao (manifestation of disease). They interact both as cause and effect. The clinical manifestations of the disease vary at the different stage, sometimes signs of deficiency are predominant, sometimes signs of excess predominant.-sometimes signs of blood stasis become more, sometimes signs of turbid toxin more; and sometimes signs of damp-heat are the main. In clinical treatment, Biao (manifestation of disease) and Ben (root of disease) should be distinguished, treat Biao (manifestation of disease) for acute case and treat Ben (root of disease) for chronic case.
Classifying the category and stage of the disease
Clinically, diabetic foot is divided into 3 categories:
Type I : It is caused by deficiency of qi and blood, malnutrition of the meridians and collaterals as well as injury of the meridians by blood stasis and turbid toxin; gangrene appears gradually in the order of skin -- muscle -- tendon -- bone.
Type II: It is caused by deficiency of both yin and yang, insufficiency of essence and marrow, malnutrition of blood vessels and retention of cold and blood stasis; gangrene appears gradually in the order of vessel -- skin -- muscle -- tendon -- bone.
Type III: It is caused by blockage of blood vessels by blood stasis, malnutrition of the meridians and collaterals, invasion of exogenous pathogenic damp, heat and toxin. Gangrene appears in the order of vessel -- skin -- muscle -- tendon - bone. Each type is subdivided into three stages:
Stage I : The skin color changes to dark purple, or with some injuries, but the patient can still have normal work and life.
Stage II: Muscles and tendons are injured, the patient lose the ability of normal life and work.
Stage III: Tendons, vessels and bones are injured, the patient is disabled.
Category and stage of the disease should be distinguished seriously to weigh the mild and severe conditions as well as the chronic and acute syndromes, to see if the patient is suitable to have acupuncture and moxibustion only, or have integrating treatment of acupuncture and drugs, or not suitable to have acupuncture treatment.
How we treat foot gangrene?