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When the disease begins, there is no thirst, the mouth is moist and the tongue is harmonious, the mental state is normal, without rash or sudden urgency, and conduct follows propriety; this is auspicious. Initially, the lesion appears like a hemp seed, with heat and pain, swelling of the entire finger, but if the base is gathered and constricted, it is auspicious. When fully developed, the head becomes necrotic, the flesh is not purple-black, pain occurs at intervals, and swelling subsides after pus discharge; this is auspicious. After ulceration, pus discharges first followed by necrotic tissue, the flesh color is red and vibrant, the toxin does not spread, and the odor is not fishy or foul; this is auspicious.

If before the sore appears there is thirst, excessive craving for cold drinks, drowsiness with a dry tongue, frequent urination, and impotence, it is inauspicious (adverse prognosis). Initially, the lesion is like a millet grain, the flesh immediately turns purple, there is no swelling but piercing pain, and black gas spreads; this is inauspicious. When fully developed, the sore shape is withered and sunken, the flesh is black and skin scorched, pain feels like being carved by a knife, and the toxin transmits to healthy fingers; this is inauspicious. After ulceration, the flesh is withered and tendons rot, blood and water discharge with foul sweat, pain is agonizing to the heart and penetrates to the bone; this is inauspicious.

Tuo Ju (Gangrene of the digits) mostly occurs on the toes and rarely on the fingers. If yellow blisters appear initially, moxibustion should be applied immediately. If it starts like a millet grain, capable of holding a grain inside, with purple-red skin color and no swelling, moxibustion should still be applied during flare-ups. After moxibustion, the sore receives fire energy, forms blisters and pus; external medications should be used to encircle and protect, while internal medications should tonify and expel toxins. If the toxic pathogen has established itself, the sore shape sinks slightly, but the purple discoloration has not attacked the instep, amputation may be considered. After amputation, if blood and water drip continuously and pain persists, harmonize Qi and Blood, and tonify Spleen and Stomach. If fully developed with reduced diet, physical fatigue, frequent urination, and dry mouth, nourish fluids and strengthen Kidney Water. After rupture, if Qi and Blood are injured, Spleen and Stomach are weak, with spontaneous sweating, night sweats, nausea, dry vomiting, restless sleep, afternoon fever, severe pain, irritability, delirium, all require major tonification of Qi and Blood.

Those from wealthy families who consume rich foods, indulge in lust, frequently use aphrodisiac methods, and have indulged for a long time, should prohibit amputation.

A man near fifty years old had a millet-grain-sized lesion on his right little toe, which gradually became a white blister. Pain started only after three days, prompting him to seek treatment. The head was already necrotic, and the finger was purple and swollen; this was Tuo Ju. Immediately, thirteen moxa cones were applied directly until severe pain ceased. Then, the top of the moxa site was pricked with a needle, a Chan Su (Toad Venom) cake was applied over the moxa, and an ointment covered the finger. Seven or eight punctures were made on the swollen area with a lancet to release toxic blood, followed by applying thickly ground Chan Su paste. Outside the swelling, Zhen Jun Miao Tie San (Miraculous Paste of the True Lord) was applied to protect healthy flesh from invasion. At that time, the patient had a rapid pulse, alternating chills and fever, nausea, and fatigue. First, Renshen Baidu San (Ginseng Detoxifying Powder) was used to resolve exterior symptoms, then Huanglian Neishu Tang (Coptis Internal Purging Decoction) to unblock the bowels, stopping nausea and fever. Subsequently, Tuoli Xiaodu San (Interior-Supporting Toxin-Expelling Powder) with Jinyinhua (Honeysuckle) and Niuxi (Achyranthes) was taken for several doses. In the morning, Bawei Wan (Eight-Ingredient Pill) was taken, and in the evening, Lafan Wan (Beeswax-Alum Pill) alternately. Fortunately, the moxibustion vented the toxic qi, and subsequent needle pricking released toxins, preventing deterioration. The toxin transformed into pus, and swelling stopped spreading. Later, Shiquan Dabu Tang (Ten-Agent Great Tonifying Decoction) with Shanzhuyu (Cornus), Wuweizi (Schisandra), and Maidong (Ophiopogon) was used for over a month until recovery. If this gangrene had not been treated with acupuncture and moxibustion to vent toxins, relying solely on topical applications and harsh purgatives would have damaged Yuan Qi, making it impossible to prevent toxin invasion.

A merchant developed a purple blister on his right second toe with extreme itching and pain. The next day, the nail turned purple and nearly black. Examination revealed toxicity in the Liver and Kidney meridians. He asked how to distinguish it. I said: Nails are the surplus energy of the Liver; purple nails indicate Liver toxicity. Bones are the surplus of the Kidneys; black bones indicate Kidney injury, which is clear logic. He asked the cause. I said: Labor fatigue injures the Liver; mistaken consumption of hot medicines injures the Kidneys. An observer noted: Indeed, he lived as a traveler, engaged with prostitutes, indulged heavily, took Yang-tonifying pills day and night, and engaged in sexual activity for two years.

This confirmed the diagnosis of labor and hot medicine injuring the Kidneys and sinews. The condition was critical, and I initially declined treatment. However, he pleaded to return alive from his journey. After consideration, I took ten hairs from the prostitute's head, twisted them into a thread, and tightly bound the distal end of the affected finger. Three moxa cones were placed evenly above the binding on the purple area, each burned seven times, covered with Chan Su paste. The swelling and pain were unbearable. After removing the hair binding overnight, the entire finger turned black, indicating death of bone, tendon, skin, and flesh. A sharp knife was used to amputate the finger along the joint line, revealing cold, foul matter. It was pre-soaked in Licorice Decoction for a long time. Once stasis cleared, Zhixue San (Hemostatic Powder) was sprinkled. The next day, the purple color at the moxa site persisted, fearing upward spread, Shen Deng Zhao Fa (Divine Lamp Illumination Method) was used. After blood dispersed and skin wrinkled, Chan Su Wan material mixed with Haiyang (Sea Sheep/likely a specific marine substance) was applied twice daily. Swelling ceased, purple turned red, and redness ulcerated into pus. Topical agents for generating flesh, relieving pain, invigorating blood, and astringing were used externally. In the morning, Shenzhu Dihuang Gao (Ginseng-Atractylodes-Rehmannia Ointment) was taken to support True Yuan; midday, Spleen-strengthening herbs restored Stomach Qi; evening, Jinye Dan (Golden Elixir Pill) resolved drug toxicity. After three months of regulation, he recovered.

A middle-aged obese woman suffered from Xiao Ke (Wasting-Thirst) for three years. Her right index finger itched and went numb for over a month, developing a small blister at the distal interphalangeal joint. The finger swelled with unbearable pain and fullness. The original blister site showed black spots, and half the finger turned purple-black. This was extreme Yang hyperactivity leading to Tuo Ju. Pulse was surging, rapid, and forceful, contrary to typical obesity patterns. If blackness spread further, necrosis would accelerate. Inquiry revealed she was formerly wealthy but childless, indulged in rich foods, used heating charcoal, took many fertility-promoting hot medicines, lost her husband in middle age, and had her estate squandered by heirs, leading to prolonged depression. Living with her widowed mother, she felt lonely. This was a case of Shi Rong (Loss of Glory) due to decline from wealth to poverty and unfulfilled desires. I refused treatment. She and her mother pleaded repeatedly. Reluctantly, following Sun Simiao’s method, I decided to cut where the finger was involved. First, Renshen Yangrong Tang (Ginseng-Nourishing Harmony Decoction) was given. Then, a soft silk strip about one chi long was wrapped around the healthy flesh at the boundary of the black area, tightened gradually to restrict blood flow. A sharp knife was used to amputate at the joint. The hand was immersed in warm Licorice water briefly; bleeding was minimal, and pain was tolerable. The patient said fear masked the pain, attributing it to divine protection. I warned that lack of pain indicated death of Qi, Blood, bone, and tendon; although the digit was gone, cure was uncertain. Large doses of Bawei Wan with Ginseng and Maidong were decocted to save Kidney Water and support Spleen/Stomach, interspersed with Jin Ye Wutu Dan to resolve drug toxicity. After three days, the binding was loosened to restore circulation. Hong and Hei Gao (Red and Black Ointments) were applied to generate flesh and relieve pain. Subsequently, the dorsum and palm swelled severely, though not black, indicating internal toxin expulsion. Shen Deng Zhao Fa was used again, along with Pig Trotter Decoction washes. Several abscess heads appeared, draining pus and blood. Two months later, swelling subsided slightly, and pus decreased. Shenzhu Gao and Renshen Yangrong Tang were continued. Six months later, she stabilized. Although she survived, she lost all five fingers.

A male servant, in severe winter cold, was ordered barefoot. His feet became numb from frozen blood. The next day, all ten toes turned purple; days later, they turned completely black, numb and painless. Treatment with acrid-hot cold-dispelling and blood-invigorating fumigations failed. Amputation of all ten toes and spread to the instep were predicted, with severe joint pain. The master feared Tuo Ju. I diagnosed it as similar but not identical, predicting survival. Frequent moxibustion with mulberry wood was prescribed for warmth, blood activation, and resolving stagnant toxins. The lesions gradually necrosed and detached without spreading. Internal Spleen-tonifying and Blood-nourishing herbs were used, along with external Red and Black Ointments to grow flesh. Recovery occurred after 100 days.

A twelve-year-old maid, considered attractive, had her feet tightly bound with cloth and sewn shut by her new master due to large foot size, causing unbearable pain. Half a month later, foul water drained upon unbinding. The anterior halves of both feet were black and necrotic; bone and flesh were dead. I stated that dead tissue cannot revive, only the remaining healthy part could be saved. Ginseng porridge was fed first, then scallion decoction was used for washing and soaking. Necrotic flesh was trimmed sequentially. Huarui Shi San (Flower Stalactite Powder) was applied where pain persisted. Life was preserved, and necrotic parts detached. Internal Buzhong Yiqi Tang (Middle-Boosting Qi-Invigorating Decoction) supported exhaustion, and external Shengji Yuhong Gao (Flesh-Generating Jade Red Ointment) promoted healing. Although healed, lifelong disability resulted from the injury.

A man developed a yellow millet-like blister in the cleft of his right little toe. Skin and flesh turned purple, with yin-region pain but no swelling, feeling like knife stabbing. Diagnosis was true Tuo Ju. Pulse was fine, rapid, and weak, indicating Kidney Meridian depletion. Given his history of heavy drinking and multiple wives, his essence was exhausted. Treatment would be futile. I refused. The condition progressed to perforation of the instep and sole, unceasing pain, reduced diet, declining Qi and Blood, emaciation, and death after two months in agony.