《灵枢》云∶发于足指，名曰脱痈。其状赤黑者死，不治。不赤黑者，不死，治之不
衰，急斩之，否则死矣。 《鬼遗》云∶ 敦疽，发两足指，五日不穴死，四日可刺，其
色发黑痈者，不堪，未过节者，可治。足指生疔，重者溃而自脱，故曰脱疽。 或曰∶惟
足大指患之为脱疽；其余足指患之，曰敦疽易治。惟脱疽难治。初发结毒， 赤肿痛者，
以五神散及以紫河车、金线钓葫芦、金鸡舌，金脑香，捣烂敷，及以汁涂敷。又以万病解
毒丸，磨醋暖涂之。未成 痛者，除湿攻毒，更以隔蒜灸之至不痛，用十二经消毒散加引
经药。若肿势盛，未得紧急者，宜作蛇伤治之；及作瘴气治之效。未成 痛，或不痛，或
大痛者，宜隔蒜灸，更用解毒，以消毒万全汤，临证加减。未成，若色黑，急割去。速
服补剂，庶可救。若黑延上，不可治。未成，若色赤 痛者，托里消毒更兼灸，以人参败
毒散去桔梗、加赤牛膝、银花、白芷、大黄，痛止，次以十宣散加天花粉、金银花、赤牛
膝。未成欲成，若色紫不痛，隔蒜灸五十壮，尚不知痛，又明灸之。服活命饮，次以托里
散，溃脱而愈。未成欲成大痛，色赤而肿，隔蒜灸至痛止，以加味荆芥败毒散加赤牛膝、银
花、白芷、大黄；次以活命饮。
〔薛〕 脱疽，因醇酒炙爆，膏粱伤脾，或房劳损肾，故有先渴而后患者，有先患而
后渴者。若色赤作痛，自溃者可治。色黑不溃者不治。色赤作痛者，元气虚而湿毒壅盛
也，先用隔蒜灸，活命饮、托里散，再用十
全大补汤，加减八味丸。色黯不痛者，肾气败而虚火盛也，隔蒜灸、桑枝灸，亦用十全
大补汤，加减八味丸，则毒瓦斯不致上浸，元气不致亏损，庶可保生。亦有因修手足、口
咬等伤而致者，若元气虚弱，或犯房事，外涂寒凉，内服克伐，损伤脾胃，患处不溃，若
黑黯上延，亦多致死。重者须当以脚刀转解周界，轻拽去之，则筋随骨出，而毒得泄，亦
不痛。否则毒筋内断，虽去而仍溃，且偏僻之处，气血罕到，药难导达。况攻毒之剂，先
伤脾胃，不若灸法为良，重者须解去为善。故孙真人云∶在肉则割，在指则截。盖亲之遗
体，虽不忍伤，而遂至夭殁，则尤伤矣。况解法无痛，患者知之。 一人足指患此，
痛色赤，发热，隔蒜灸之，更以人参败毒散去桔梗，加金银花、白芷、大黄，二剂痛止，
又十宣散去桔梗、官桂加天花粉，数剂而平。一人年逾四十，左足大指赤肿 痛，此脾
经积毒下注而然，名曰脱疽。喜色赤而肿，以人参败毒散去人参、桔梗，加金银花、白芷、
大黄二剂，更以金银花、甘草节、栝蒌，四剂顿退，再以十宣散去桔梗、桂，加金银花、
防己，数剂愈。 一人患此，色紫赤不痛，隔蒜灸五十余壮尚不痛，又明灸百壮方知，乃
以败毒散加金银花、白芷，数剂而愈。 一膏粱，年逾五十亦患此，色紫黑，脚 痛。孙
真人曰∶脱疽之证，急斩之去毒，延腹必不治，色黑不痛者，亦不治。喜其饮食如故，动
息自宁，为疮善证，遂以连翘败毒散六剂，更以金银花、甘草节、栝蒌二十余剂，患指溃
脱，更以芎、归、生 、连翘、金银花、白芷，二十余剂而愈。次年忽发渴，服生津等
药愈甚，服八味丸而止。大抵此症皆由膏粱浓味，或房劳太过，丹石补药所致，其发于
指，微赤而痛可治，治之不愈，急斩去之，庶可保，否则不治。色紫黑或发于脚背，亦不
治。或先渴而后发，或先发而后渴，色紫赤不痛，此精气已竭，决不可治。 一 荛，左
足指患一泡，麻木色赤，次日指黑，五日连足黑冷，不知疼痛，脉沉细，此脾胃受毒所
致。进飞龙夺命丹一服，翌日令割去足上死黑肉，割后骨始痛可救，治以十全大补汤而
愈。盖死肉乃毒瓦斯盛，拒截荣气所致，况至阴之下，血气难达。经云，风淫末疾是也。向
若攻伐之，则邪气乘虚上侵，必不救矣。一人足指患之，大痛色赤而肿，隔蒜灸之痛
止，以人参败毒散去桔梗，加金银花、白芷、大黄而溃，更以仙方活命饮而痊。 一人足
指患之，色黑不痛，令明灸三十余壮而痛，喜饮食如常。予谓∶急割去之，速服补剂。彼
不信，果延上，遂致不救。 一人足指患之，色紫不痛，隔蒜灸五十余壮，尚不知痛，又
明灸百壮始痛，更投仙方活命饮四剂，乃以托里药溃脱而愈。 一人足指患之，色赤
痛作渴，隔蒜灸数壮，以仙方活命饮三剂而溃，更服托里药，及加减八味丸，溃脱而愈。
若早用前法，不至于此。 一膏粱之人，先作渴足热，后足大指赤痛，六脉洪数而无力，
左尺为甚，予谓∶此足三阴虚，当滋化源为主。固服除湿败毒等药，元气益虚，色黯延
足。予乃朝用补中益气汤，夕用补阴八珍汤，各三十余剂，及桑枝灸，溃而脓清，作渴不
止，遂朝以前汤送加减八味丸，夕用十全大补汤三十余剂而痊。是时同患此证，服败毒
之药者，俱不救。
附方
五神散 搽一切瘴毒、蛇伤、蝎螫，大效。
金线钓葫芦 紫河车（各二钱） 续随子（去壳） 雄黄（各一钱） 麝香（少许）
上末。醋调涂患处，蛇伤以刀割去损肉，以末干搽，或以唾调搽，或加骑蛇狮子根叶，
同前捣用，亦妙。
洗瘴方
水苦荠 槐枝叶 柳枝叶 嫩 叶 小青叶 连 大青
上煎水，浸洗。
*Ling Shu* (Spiritual Pivot) states: A condition occurring on the toes is named Tuoyong (Sloughing Gangrene). If the lesion appears red and black, it is fatal and untreatable. If it is not red or black, it is not fatal; however, if treatment fails to alleviate the condition, urgent amputation is required, otherwise death will ensue. *Gui Yi* (The Legacy of Ghosts) states: Dunju (Dun Abscess) occurs on both big toes. If puncture is not performed within five days, death will occur; it can be pricked within four days. If the color turns black and an abscess forms, it is incurable; if the disease has not crossed the joint, it is treatable. When a Ding sore (hard carbuncle) arises on the toe, in severe cases it ulcerates and falls off spontaneously, hence the name Tuoju (Sloughing Gangrene).
Some say: Only when the big toe is affected is it called Tuoju; when other toes are affected, it is called Dunju and is easy to treat. Only Tuoju is difficult to treat. In the initial stage, when toxins bind causing redness, swelling, and pain, apply Wushen San (Five Gods Powder) along with Ziheche (Placenta), Jinxiandiao Hulu (Golden Thread Hooking Gourd), Jinjishe (Golden Chicken Tongue), and Jinnao Xiang (Golden Brain Incense), pounded into a paste for external application, and use their juice for smearing. Also apply Wanbing Jiedu Wan (Ten Thousand Diseases Detoxifying Pill) ground in vinegar and warmed for topical use. For those without formed pus, employ methods to drain dampness and attack toxins, combined with Garlic-Separated Moxibustion until pain ceases, then administer Shierjing Xiaodu San (Twelve Meridians Detoxifying Powder) with guiding herbs. If swelling is severe but not yet critical, treat as snakebite; treatment for miasma qi is also effective. For unformed pus, whether painless or severely painful, use Garlic-Separated Moxibustion combined with detoxification using Xiaodu Wanquan Tang (Detoxifying Complete Safety Decoction), modified according to symptoms. If unformed pus presents with black color, urgent excision is required. Rapidly administer tonics to potentially save the patient. If blackness spreads upward, it is untreatable. For unformed pus with red color and pain, use interior-supporting and detoxifying methods combined with moxibustion, prescribing Renshen Baidu San (Ginseng Detoxifying Powder) removing Jiegeng (Platycodon), adding Chiniuxi (Achyranthes), Yinhua (Honeysuckle), Baizhi (Angelica Dahurica), and Dahuang (Rhubarb); once pain stops, follow with Shixuan San (Ten Acupoints Powder) adding Tianhuafen (Trichosanthes Root), Yinhua, and Chiniuxi. For unformed pus nearing formation, if purple and painless, perform fifty moxa cones of Garlic-Separated Moxibustion; if still painless, perform direct moxibustion. Admin Huoming Yin (Life-Saving Decoction), followed by Tuoli San (Interior-Supporting Powder); recovery follows after ulceration and sloughing. For unformed pus nearing large-scale pain, red and swollen, perform Garlic-Separated Moxibustion until pain ceases, then use Jiawei Jingjie Baidu San (Modified Schizonepeta Detoxifying Powder) adding Chiniuxi, Yinhua, Baizhi, and Dahuang; subsequently use Huoming Yin.
[Xue Ji] Tuoju results from consuming rich wine and roasted/fried foods damaging the Spleen, or from sexual exhaustion damaging the Kidney. Thus, some present with thirst preceding the disease, while others have the disease preceding thirst. If red and painful, capable of spontaneous ulceration, it is treatable. If black and unable to ulcerate, it is untreatable. Red and painful indicates deficient Yuan Qi (Original Qi) and abundant damp-toxin stasis; initially use Garlic-Separated Moxibustion, Huoming Yin, and Tuoli San, then use Shiquan Dabu Tang (Complete Great Tonifying Decoction) and Jiawei Bawei Wan (Modified Eight Immortals Pill). Dark and painless indicates failed Kidney Qi and flourishing deficiency fire; use Garlic-Separated Moxibustion and Mulberry Branch Moxibustion, also employing Shiquan Dabu Tang and Jiawei Bawei Wan, so that toxin vapors do not spread upward and Yuan Qi is not depleted, potentially preserving life. It may also result from injuries such as trimming nails or bites; if Yuan Qi is weak, or if sexual activity is indulged, cold-cooling agents are applied externally, and harsh purgatives taken internally, damaging the Spleen and Stomach. If the lesion does not ulcerate and blackness spreads upward, death often ensues. In severe cases, one must use a foot knife to incise around the periphery and gently pull away necrotic tissue, allowing tendons to emerge with bone and toxins to drain, resulting in no pain. Otherwise, toxic tendons break internally; even if removed, ulceration persists. Moreover, in remote areas where blood and Qi rarely reach, drugs are hard to deliver. Furthermore, toxic-attacking agents first damage the Spleen and Stomach; moxibustion is superior. Severe cases require excision. Thus, Sun Simiao said: If in flesh, cut it out; if in fingers/toes, amputate. Although one hesitates to harm the body inherited from parents, dying prematurely is a greater harm. Excision is painless, and patients know this.
One case: A patient had this on the toe, red and painful, with fever. After Garlic-Separated Moxibustion, Renshen Baidu San removing Jiegeng, adding Yinhua, Baizhi, and Dahuang was given for two doses, stopping pain. Then Shixuan San removing Jiegeng and Guigui (Cinnamon Twig) adding Tianhuafen was given for several doses, leading to resolution.
Another case: A man over forty had red, swollen, painful left big toe, caused by accumulated toxins in the Spleen meridian sinking downward, named Tuoju. Being red and swollen, Renshen Baidu San removing Renshen and Jiegeng, adding Yinhua, Baizhi, and Dahuang was given for two doses. Then Yinhua, Gancao Jie (Licorice Joint), and Gualou (Trichosanthes Fruit) were given for four doses, rapidly reducing symptoms. Then Shixuan San removing Jiegeng and Gui, adding Yinhua and Fangji (Stephania) was given for several doses, leading to cure.
Another case: A patient had this, purple-red and painless. After more than fifty Garlic-Separated Moxibustion cones, still painless, direct moxibustion of one hundred cones induced pain. Then Baidu San adding Yinhua and Baizhi was given for several doses, leading to cure.
A person accustomed to rich food, over fifty, suffered from this, purple-black color, foot pain. Sun Simiao said: In Tuoju, urgently amputate to remove toxins; if it spreads to the abdomen, it is untreatable. Black and painless is also untreatable. Fortunately, his diet and rest were normal, indicating a favorable prognosis. Lianqiao Baidu San (Forsythia Detoxifying Powder) was given for six doses, then Yinhua, Gancao Jie, and Gualou for over twenty doses. The affected toe ulcerated and sloughed off. Then Chuanxiong (Ligusticum), Danggui (Angelica Sinensis), Shengdi Huang (Rehmannia), Lianqiao, Yinhua, and Baizhi were given for over twenty doses, leading to cure. The next year, sudden thirst occurred; taking fluids-generating medicines worsened it, but Bawei Wan stopped it. Generally, this syndrome is caused by rich food, excessive sexual activity, or cinnabar/stone tonics. Onset on toes with slight redness and pain is treatable; if treatment fails, urgent amputation preserves life, otherwise it is untreatable. Purple-black color or onset on the dorsum of the foot is untreatable. Thirst preceding or following onset, purple-red and painless, indicates exhaustion of Essence and Qi, absolutely untreatable.
One case (Rao): A blister appeared on the left toe, numb and red. The next day the toe turned black; within five days the whole foot became black and cold, with no sensation of pain. Pulse was deep and fine, indicating toxins affecting the Spleen and Stomach. One dose of Feilong Duoming Dan (Flying Dragon Snatching Life Pill) was administered. The next day, dead black flesh was cut off. Bone pain ensued, indicating salvageability. Treatment with Shiquan Dabu Tang led to recovery. Dead flesh is caused by abundant toxin vapors rejecting Ying Qi (Nutritive Qi). Moreover, at the extreme yin location (feet), blood and Qi struggle to reach. The Classics state: Wind excess causes diseases in the extremities. Had aggressive purging been used earlier, pathogenic factors would have invaded due to deficiency, ensuring no salvation.
Another case: Toe affected, severe pain, red and swollen. Garlic-Separated Moxibustion stopped pain. Renshen Baidu San removing Jiegeng, adding Yinhua, Baizhi, and Dahuang led to ulceration. Xianfang Huoming Yin (Immortal Formula Life-Saving Decoction) led to recovery.
Another case: Toe affected, black and painless. Direct moxibustion of thirty-plus cones induced pain. Diet was normal. I advised urgent excision and rapid tonic administration. He did not believe me; indeed, it spread upward, leading to death.
Another case: Toe affected, purple and painless. Garlic-Separated Moxibustion of fifty-plus cones did not induce pain; direct moxibustion of one hundred cones induced pain. Four doses of Xianfang Huoming Yin were given, followed by interior-supporting medicines leading to ulceration, sloughing, and recovery.
Another case: Toe affected, red, painful, with thirst. Several Garlic-Separated Moxibustion cones were applied. Three doses of Xianfang Huoming Yin led to ulceration. Interior-supporting medicines and Jiawei Bawei Wan were taken, leading to ulceration, sloughing, and recovery. Early application of previous methods would have prevented this.
A person accustomed to rich food: First thirst and hot feet, then red painful big toe. Six pulses were surging and rapid but forceless, especially the left Chi pulse. I diagnosed deficiency of the three Foot Yin meridians, prioritizing nourishing the source of transformation. Persisting in draining dampness and detoxifying medicines further depleted Yuan Qi, with dark color spreading up the foot. I prescribed Buchong Yiqi Tang (Tonify Middle and Boost Qi Decoction) in the morning and Buyin Bazhen Tang (Nourish Yin Eight Treasures Decoction) in the evening, each for over thirty doses, plus Mulberry Branch Moxibustion. Ulceration occurred with clear pus. Thirst persisted. Morning doses of the former decoction were taken with Jiawei Bawei Wan; evening doses of Shiquan Dabu Tang for over thirty doses led to recovery. At that time, others with this condition taking detoxifying medicines all died.
Attached Formulas
Wushen San (Five Gods Powder) Applied to all miasma toxins, snakebites, and scorpion stings; highly effective.
Jinxiandiao Hulu (Golden Thread Hooking Gourd)
Ziheche (Human Placenta) (2 qian each)
Xuisui Zi (Euphorbia lathyris seed, shell removed)
Xionghuang (Realgar) (1 qian each)
Shexiang (Musk) (a small amount)
Grind into powder. Mix with vinegar and apply to the lesion. For snakebites, cut away damaged flesh with a knife, then dry-dust with powder, or mix with saliva for application. Adding Qishe Shizi Genye (Roots and leaves of *Sarcostemma viminale*) and pounding together as before is also excellent.
Xi Zhang Fang (Miasma Washing Formula)
Shuikuqi (Nasturtium officinale)
Huai Zhi Ye (Locust tree branches and leaves)
Liu Zhi Ye (Willow branches and leaves)
Nen Ye (Tender leaves)
Xiao Qing Ye (Small green leaves)
Lianqiao (Forsythia)
Da Qing (Isatis Leaf)
Decoct in water and soak/wash.