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Xue Ji stated: Tuojü (Gangrene of the toes/fingers), refers to Dingchuang (Malignant carbuncle) occurring on the foot or toes. In severe cases, it ulcerates and falls off, hence the name. There are also cases occurring on the fingers, called Zhujie Ding (Cavity-joint Malignant Carbuncle). In severe cases, rot extends to the proximal phalanx; in mild cases, there is tendon contraction. This condition is indeed caused by accumulated toxins from a diet rich in fatty foods and sweet flavors, alcohol, wheat products, and fried or roasted foods. It may also result from imprudent sexual activity leading to exhaustion of Kidney Water (Jing/Essence and Body Fluids), or from taking Dan Shi (Cinnabar and Pyrite) tonics, causing thirst before onset or onset before thirst. All these stem from the deficiency and dryness of Kidney Water, failing to control Fire. Although the local manifestation of this condition seems minor, its malignancy is great. Regardless of swelling or ulceration, Garlic-partitioned Moxibustion must be applied. If painless, strong moxibustion should be used to hopefully reduce the toxicity. Cases presenting with black color upon initial onset without ulceration are incurable. Cases where toxin spreads into the abdomen are incurable. Cases with black color and no pain are also incurable. Cases with red color, pain, and spontaneous ulceration are treatable. If the toxin is not resolved promptly, leading to necrosis and blackening of the flesh, urgent amputation is required. Some cases arise from injuries such as trimming hands/feet or animal bites. If the Original Qi (Yuan Qi) is weak, or if sexual activity is indulged, or if cold-cooling agents are applied externally and attacking/clearing herbs are taken internally, damaging the Spleen and Stomach, the affected area may fail to ulcerate, or blackness may spread upward to the foot, often resulting in death. In severe cases, a foot knife must be used to rotate and cut around the bone, gently pulling out the necrotic tissue so that tendons follow the bone out, allowing the toxin to be discharged, which will also relieve pain. Otherwise, the toxic tendons break internally, and even after removal, the wound continues to ulcerate. Moreover, in remote areas, Qi and Blood rarely reach, making it difficult for medicines to penetrate. Furthermore, detoxifying agents first damage the Spleen and Stomach, further depleting Original Qi, whereas moxibustion is superior. For severe cases, excision is best. Thus, Sun Simiao said: "If in the flesh, cut it; if in the finger, amputate." Without doing so, premature death is inevitable, and the harm is even greater. Since the affected area is already necrotic, even if excised, it causes no pain, so why hesitate? Patients should understand this. If women suffer from this, it is often due to tight binding (foot-binding), obstructing blood vessels, leading to dead flesh. Treatment should focus on strengthening the Spleen and Stomach, unblocking meridians, and generating Qi and Blood to achieve recovery.

Furthermore, "Treatment Methods" states: Red color with pain indicates Original Qi deficiency and accumulation of Damp-Toxin. First apply Garlic-partitioned Moxibustion, then use detoxifying formulas such as Xian Fang Huo Ming Yin (Immortal Life Saving Decoction) or Tuo Li San (Support Interior Powder). Quickly administer tonics such as Shi Quan Da Bu Tang (Comprehensive Great Tonifying Decoction) or Jia Jian Ba Wei Wan (Modified Eight-Ingredient Pill), so that toxin does not invade upward and Original Qi is not depleted, ensuring survival. Thirst should be treated by nourishing Yin and descending Fire. Black color indicates incurability.

Cui's Formula treats Shou Zu Jiu Ju (Nail Gangrene of hands and feet), whether caused by trimming nails injuring flesh or foot injury forming ulcers spreading to the leg. Use Lv Fan (Green Vitriol). Place it on an iron plate and heat until it turns red like molten gold, indicating authenticity. After cooling, grind into powder. Wash with salt water and apply topically.

A male patient suffered from toe involvement, with pain, redness, and fever. He underwent Garlic-partitioned Moxibustion, followed by Ren Shen Bai Du San (Ginseng Detoxification Powder) minus Jie Geng, added with Jin Yin Hua, Bai Zhi, and Da Huang. After two doses, pain ceased. Then, Shi Xuan San (Ten Acupoints Powder) minus Jie Geng and Guan Gui, added with Tian Hua Fen and Jin Yin Hua, was administered for several doses, resulting in recovery.

Another male patient had toe involvement with purple color and no pain. He received over fifty moxa cones via Garlic-partitioned Moxibustion but felt no pain. Strong moxibustion of one hundred cones induced pain. Subsequently, Xian Fang Huo Ming Yin was given for four doses, followed by interior-supporting medicine, leading to ulceration, detachment, and recovery.

A patient accustomed to rich diets initially presented with thirst and hot feet, followed by red painful big toe. The six pulses were surging and rapid but forceless, especially at the Left Chi position. I diagnosed this as a deficiency syndrome of the Three Yin Meridians of the Foot, primarily requiring nourishment of the source of transformation. He had previously taken damp-clearing and detoxifying agents, further depleting his Original Qi, with dark discoloration spreading to the foot. I prescribed Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) in the morning and Bu Yin Ba Zhen Tang (Nourish Yin Eight Treasure Decoction) in the evening, each for over thirty doses, along with Sang Zhi Moxibustion (Mulberry Twig Moxibustion). Ulceration occurred with clear pus, but thirst persisted. I then administered Jia Jian Ba Wei Wan (Modified Eight-Ingredient Pill) with the morning formula and Shi Quan Da Bu Tang in the evening for over thirty doses, resulting in recovery. At that time, others with similar conditions taking detoxifying agents showed no effect.

Another patient accustomed to rich diets, over fifty years old, suffered from this condition with purple-black color and foot pain. Fortunately, his appetite remained normal, and he moved/rested comfortably, indicating a favorable prognosis for a sore/ulcer, thus treatable. I prescribed Lian Qiao Xiao Du San (Forsythia Detoxification Powder) for six doses, followed by Jin Yin Hua, Gan Cao Jie, and Gua Lou for over twenty doses. The affected finger ulcerated and detached. Finally, Dang Gui, Chuan Xiong, Lian Qiao, Sheng Di, Jin Yin Hua, and Bai Zhi were administered for over twenty doses, resulting in recovery.

A woodcutter developed a blister on his left toe, numb with redness. The next day, the toe turned black. By the fifth day, the entire foot was black and cold, with no sensation of pain. The pulse was deep and fine. This was caused by toxin affecting the Spleen and Stomach. One dose of Fei Long Duo Ming Dan (Flying Dragon Life-Snatching Pill) was given. The next day, necrotic flesh on the foot was surgically removed. Bone pain appeared post-surgery, indicating salvageability. He was then treated with Shi Quan Da Bu Tang and recovered. Necrotic flesh is caused by abundant toxin rejecting Ying Qi (Nutritive Qi) circulation. Moreover, in the lowest Yin regions, Qi and Blood struggle to reach. The Classics state: "Wind excess leads to diseases of the extremities," which applies here. Had attacking methods been used initially, Original Qi would have been further depleted while pathogenic factors intensified, invading upward through deficiency, inevitably leading to untreatable conditions. (All notes by Xue Ji)