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(Also known as Yue Zu Shang Han [Cold Damage to the Amputated Foot], or Zhi Tuo [Limb Detachment]).

[Etiology] There are approximately three causes. First, walking barefoot on snow and then suddenly washing feet with hot water, forcing cold-dampness to penetrate deeply into the limb joints. Second, Shang Han transforming into heat and dryness; excessive drinking of cold water due to thirst, while the body does not sweat, causing water qi to overflow into the limb joints. Third, walking barefoot on manure ground that has been baked by the scorching sun, inhaling toxic vapors, and then suddenly washing feet with cold water, forcing heat-toxin to penetrate deeply into the limb joints. All these can lead to limb detachment.

[Manifestations] Initially, there is aversion to cold with fever, and swelling of the feet, resembling Hong Kong Foot (Tinea Pedis/Erysipelas), but the skin color is purple and dark, and the limb joints feel numb and painful. Subsequently, fluid oozes incessantly from between the toes, and the toes swell and hurt, appearing ulcerated yet not fully ulcerated; one must guard against ulceration and falling off. The tongue coating is mostly white and putrid, or yellow and putrid with black spots. If heat-toxin penetrates deeply into the limb joints, both shins will be red, swollen, and painful, with the patient groaning and crying, unable to sleep day or night, and the tongue body is often purple-red with prickles.

[Pulse] A wiry and tight pulse on the left, and a deep, wiry, and choppy pulse on the right, indicates cold-dampness or water qi sinking to the lower legs. If both Chi positions show wiry, slippery, rapid, and forceful pulses, it indicates heat-toxin lingering in the lower legs.

[Treatment] For cases caused by cold-dampness and water qi, internally administer Da Ju Pi Tang (Large Tangerine Peel Decoction), adding raw Yi Yi Ren (Coix Seed), fresh Che Qian Cao (Plantago Leaf), each two liang, and Du Chi Xiao Dou (Red Adzuki Beans), one liang (these three ingredients are decocted in water to replace normal water for decocting other herbs). Promote urination to expel water-dampness. Externally, first use a washing method: Qiang Huo (Notopterygium Rhizome), Fang Feng (Saposhnikovia Root), Bai Zhi (Angelica Dahurica), Jiao Ci (Gleditsia Spine), Hong Hua (Safflower), Jiang Xiang (Dalbergia Odorifera), Gui Pi (Cinnamon Bark), Chuan Wu (Aconite Lateral Root) each five qian; Chuan Xiong (Ligusticum Rhizome), Ai Ye (Mugwort Leaf), Zhang Mu Pian (Camphor Wood Slices), You Song Jie (Pine Joint), Sang Zhi (Mulberry Twig), Cong Bai (Scallion White) each one liang. Decoct in water until boiling several times. First rinse, then wipe the affected area, avoid wind, wash three times daily and twice at night (washing after meals is more suitable). If the medicine cools, add boiled water mixed with scallion decoction to warm it. Severe cases may turn mild, and some may even dissipate solely through washing. Next, use Garlic-Separated Moxibustion: slice a single-head garlic, place it on the affected area, put moxa wool on the garlic and moxibustion. Change the garlic slice every three moxa cones. Ensure that areas without pain are moxibusted until they feel severe pain, painful areas until pain ceases, itchy areas until itching stops, and non-itchy areas until extreme itching occurs. If dry mouth, irritability, or even head and neck swelling and confusion occur, do not fear; this is a sign of Yin syndrome turning to Yang, with sudden return of Yang. Do not heavily use cooling medicines; instead, use raw Lu Dou (Mung Bean) one liang, Mai Dong (Ophiopogon Tuber) and Jing Mi (Rice) each five qian, Sheng Gan Cao (Licorice Root) one qian, decoct and drink to cure. Finally, use powder application: Qian Nian Duan Shi (Calamine prepared over a thousand years) one liang, Bai Zhi two liang, grind finely and mix evenly. Sprinkle a small amount on the lesion. When thick fluid gushes out and empties completely, it heals. Internal and external treatments combined prevent limb detachment, achieving results in seven days. For cases where heat-toxin lingers in the limb joints, internally use Da Ju Pi Tang removing Gui Zhi (Cinnamon Twig) and Bai Zhu (Atractylodes Macrocephala Rhizome), adding Jiu Chao Fang Ji (Sabiá Stem, wine-fried) two qian, Xian Guan Zhong (Cyrtomium Fortunei Rhizome) five qian, Ren Dong Teng (Honeysuckle Stem), Geng Ye (Stem Leaves), and Nen Sang Zhi (Young Mulberry Twig) each two liang (decoct first to replace water). Cool and promote urination to drive out heat-toxin. Externally, decoct Duck Feather, add Zao Fan (Alum) one liang, and wash feet while hot, three times daily, avoiding wind, curing in three days.

[Xiu's Commentary] Below the ankle is called Zu (Foot). The dorsum of the foot is called Fu (also known as Zu Die, commonly called the top of the foot). The heel is called Gen. The toes are called Zhi (Zhi distinguishes from hands; toe joints are similar to finger joints). Medially behind the proximal interphalangeal joint of the great toe, the prominent round bone is named He Gu. Behind the nail of the great toe are three hairs; the transverse crease behind them is Ju Mao. The sole touching the ground is called Zhong (commonly called the sole). In my observation of Tuo Jue (Limb Detachment), some have one foot detached, others both, collectively called Zhi Tuo. Some only have toes detached. Initially white, numb, and painful, or painless, it is named Tuo Ju (Gangrene). Initially red, swollen, and painful, like being scalded by boiling water or burned, it is named Dun Yong (Abscess). Zhi Tuo results from sleeping outdoors in autumn or summer, attacked by cold, with internal heat generation, battling in the limb joints, pain penetrating to the bone, worsening with cold, and slightly relieved by heat application. The main formula is Da Fang Feng Tang (Major Saposhnikovia Decoction): Fang Feng two qian, Dang Gui (Angelica Sinensis), Shu Di Huang (Rehmannia Glutinous Root), Sheng Huang Qi (Astragalus Root), Chuan Du Zhong (Eucommia Bark) each three qian; Dang Shen (Codonopsis Root), Bai Zhu, Qiang Huo (Notopterygium Rhizome), Chuan Xiong each 1.5 qian; Huai Niu Xi (Achyranthes Bidentata Root), Sheng Chi Shao (White Peony Root) each one qian; Dan Fu Pian (Prepared Aconite Lateral Root), Guan Gui (Cinnamon Bark), Qing Zhi Gan Cao (Prepared Licorice Root) each five fen. Zhi Tuo resulting from walking barefoot long distances in rainy, damp weather, with water qi infiltrating and lingering in limb joints, causing dull numb pain, swelling of the dorsum of the foot, and incessant oozing from toe webs, is treated mainly with Xiao Fu Tang (Eliminate Dorsum Decoction): Sheng Mi Ren (Coix Seed), Dai Pi Ling (Poria with Skin) each two liang; Mian Yin Chen (Artemisia Capillaris), Ze Xie (Alisma Rhizome) each three qian; Jiu Chao Fang Ji, Mu Gua (Chaenomeles Fruit) each one qian; Guan Gui, Cang Zhu (Atractylodes Lancea Rhizome) each 1.5 qian. Tuo Ju results from deep-seated cold and stubborn cold, with Yin toxin battling in the toe joints. Inability to flex indicates disease in the sinews; inability to extend indicates disease in the bones. It may arise on the toe tips or between toes. Initially white, then turning black, eventually ulcerating and detaching segment by segment, spreading to the dorsum and heel, with white rot and black decay, unbearable pain. Treatment should be internal and external. External: Cut open a living Toad, remove liver, gallbladder, and intestines, use only the skin, tie toes with thread to draw out toxin. Internal: Qu Du Bao Tuo Tang (Drive Out Toxin and Protect from Detachment Decoction): Dang Gui one liang, Yang Jing Gu (Sheep Tibia Bone) three qian, Gui Xin (Cinnamon Heart), Sheng Gan Cao each one qian; Hei Pao Jiang (Black Prepared Ginger), Ma Huang (Ephedra Herb), Ming Ru Xiang (Frankincense), Jing Mo Yao (Myrrh) each five fen. Invigorate blood and harmonize Yang to scatter Yin toxin. Dun Yong results from damp-heat sinking downward, also requiring internal and external treatment. External: Apply Qing Liang Shen Shi Gao (Cooling and Damp-Draining Ointment): Dissolve Kuang Duan Shi (Calamine) in a vat; the next day, take the thin ice-like layer formed on the water surface, mix with Tung Oil to a thick consistency, apply two to three times daily, full recovery in a few days, avoid pork. Internal: Xian Fang Huo Ming Yin (Immortal Life-Deciding Formula): Jin Yin Hua (Honeysuckle Flower) five qian, Hua Fen (Trichosanthes Root), Chi Shao each 1.5 qian; Fang Feng, Bai Zhi, Guang Pi (Tangerine Peel), Gui Wei (Angelica Sinensis Tail), Zao Jiao Ci (Gleditsia Spine), Sheng Gan Cao, Chuan Bei (Fritillaria Bulb) each one qian; Ha Fen (Clam Shell Powder), Chao Chuan Shan Jia (Pangolin Scale, fried), Jing Mo Yao each eight fen. Add Sheng Huai Niu Xi (Achyranthes Bidentata Root) three qian to resolve toxin stagnation. If itching and pain coexist, with rupture flowing yellow fluid, spreading in patches, and even leg muscle swelling, it belongs to Spleen and Kidney deficiency. Main formula: Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) plus Fang Feng, Du Huo (Angelica Pubescens Root). For pain, add Dan Pi (Moutan Cortex), Jiao Zhi Zi (Gardenia Fruit, charred), Chao Chuan Bai (Phellodendron Bark, fried). Concurrently take Liu Wei Di Huang Wan (Six-Ingredient Pill with Rehmannia). Externally, rinse with Guan Zhong decoction, mix Wu Bei Zi (Galla Chinensis) fine powder with saliva, apply around the four sides of the sore, contracting inward from outside, once daily, gradually self-healing. Do not recklessly administer attacking or dispersing drugs. Mr. Yu distinguished the three causes and prescribed according to symptoms, likely having much experience.

[Lian's Verification] Tuo Jue Shang Han is mostly treated by surgeons. In over thirty years of clinical practice, I have never encountered it. It is rarely seen in previous physicians' books. Only Mr. Xu Huixi recorded a case of Yue Zu Shang Han, describing a patient surnamed Huang from Jiashan. He had an external contraction complicated by stagnant heat, was given erratic medications, followed by tonics. Pathogens remained in the meridians with no exit, sinking to the feet, causing redness, swelling, and severe pain in both shins, rebellious Qi rushing to the heart, howling, and insomnia. I said this is what is called Yue Zu Shang Han; the feet are about to fall off. Urgently use external methods: fumigate and steam to raise toxins and dissipate stasis. Use pills and powders internally to resolve phlegm-fire and transform toxic saliva, excreting via stool. Use a pungent-cool decoction to push out pathogens not yet fully expressed. Peace returned in three days. Generally, when Wind-Cold remains in meridians with no outlet, it often transforms into abscesses: upper part becomes Fa Yi (Parotitis), middle part becomes Fei Yong (Lung Abscess), Gan Yong (Liver Abscess), Pi Ji (Masses); lower part becomes Chang Yong (Intestinal Abscess), Bian Du (Perianal Abscess); externally it disperses as Zhen Chuang Yang (Rashes, Sores, Ulcers); lingering in joints causes Wei Bi Ju Luan (Flaccidity, Obstruction, Spasm); sinking to lower legs causes Yue Zu (Amputation). These conditions are recorded in Nei Jing and other books. Since Internal and External Medicine separated into distinct disciplines, these conditions have been unknown. Mr. Wang's "Wen Re Jing Wei" states that modern physicians do not read Nei Jing; although treating Warm Heat, Summer-Heat, and Epidemic diseases identically to Shang Han, prohibiting cool drinks, thickening clothing and bedding, closing windows and doors, leading to death, I have seen many such cases. However, drinking cold water must be moderate; excess causes retained fluids, swelling, vomiting, and diarrhea. More commonly, after recovery, fluid oozes from fingers and toe webs. Quickly administer Qu Shi Bao Tuo Tang (Expel Dampness and Protect from Detachment Decoction): Sheng Yi Yi Ren, Zhe Fu Ling (Poria) each three liang, Sheng Bai Zhu one liang, Che Qian Zi (Plantago Seed) five liang, Gui Xin one qian. Take ten doses continuously to avoid toe detachment. This is the proverbial Tuo Jue Shang Han, which must be known. Shen Min Yuan's "Qi Zheng Hui" mentions a man with heel bone detachment, painful upon movement, difficult to walk. Master Ye Tianshi examined him and said: "This is Dampness injuring sinews." Prescribed Chao Ku Ting Li (Thladiantha Seed, fried) four liang, Chao Fang Ji, Guang Mu Xiang (Aucklandia Root), Fu Ling, Mu Tong (Akebia Stem), Ren Shen (Ginseng Root) each 2.5 qian, made into pills with jujube meat, size of sesame seeds. Take thirty pills per dose, washed down with Mulberry Bark Soup. Named Sheng Ling Dan. It cured him. From these three cases, one is internal ulceration of abscess, one is water qi sinking, one is Dampness injuring foot sinews. All can cause joint detachment, but etiologies differ, and treatments vary greatly. Each disease has its own method; medicine cannot but be broad. Mr. Xu Huixi said: Every disease has specific formulas and herbs; one cannot rely on general formulas for luck. But ignorant physicians are biased and stubborn, with few methods, unable to respond endlessly. Thus, errors occur frequently, diseases worsen, medicines fail, and they are left helpless.

[Rongzhai's Commentary] "Tuo Jue Shang Han" (Strictly speaking, it is: Tuo Zhi Shang Han [Cold Damage with Toe Detachment]. Because what detaches is the toe, not the foot.) It is mostly caused by virus sinking downward. Chao Shi's "Bing Yuan Lun" records two types: One is "Shang Han Du Gong Zu Hou" [Cold Damage Toxin Attacking Foot Syndrome]: "This is because heat-toxin vapor exits from within, follows meridians to attack the feet. The Jing, Ying, and Shu points of the five Zang and six Fu organs all emerge from the fingers and toes; thus, toxins exit from the Zang-Fu." The other is "Shang Han Du Liu Zhong Hou" [Cold Damage Toxin Flowing Swelling Syndrome]: "When human Yin and Yang are both deficient, damp-toxin vapor combats with Wind-Heat, causing Ying and Wei to become sluggish. When Ying and Wei are sluggish, Qi and Blood do not circulate. When Qi and Blood do not circulate, pathogenic heat causes stagnation, flowing and swelling along the meridians." I consider these two lines the origin of "Tuo Jue Shang Han." The cause is "Shang Han" leading to "Tuo Jue," but naming the disease "Tuo Jue Shang Han" is a case of "reversing cause and effect," common in TCM literature. Wu Kun An's "Shang Han Zhi Zhang" states: "If fever and whole-body pain accompany slight swelling of the four limbs, this is Wind-Damp flowing to hands and feet. Suitable for Er Chen Tang added with Mi Ren (Coix Seed), Gui Zhi, Qin Jiao (Gentiana Macrophylla Root), Fang Ji, Qiang Huo, Mu Gua, Pian Jiang Huang (Turmeric). For red and swollen lower legs, combine with Er Miao San." I consider this the progression of "Tuo Jue Shang Han," merely "swollen but not ulcerated." Here, emphasizing "tracing the cause from the effect" aims to "prevent minor issues from becoming major," ensuring Shang Han patients do not suffer limb detachment.

Additionally: Wang Kentang's "Yi Lun" cites "Qi Dong Mi Zhi": "After recovery from Warm Heat, residual pathogens often settle in the feet, causing fever, swelling, and pain. If not treated urgently, severe pain leads to death in many cases, or at least disability; named Jie Zu Feng [Amputation Wind]. Attached below is an effective formula: Guang Jiao (Gelatin) one liang, mixed with Jiao (Distiller's Grains), Cu (Vinegar), Jiang (Ginger Juice), Cong (Scallion Juice) four flavors, melted into paste, spread on cotton paper or red cloth, applied to the affected area, pain stops immediately. (Grains mixed with vinegar, crushed and blended, filtered juice used, dregs discarded; ginger juice need not be much, just a little; scallion juice should be half again as much as ginger juice; grain-vinegar mixture must be three to four times that of scallion juice)." This formula has been verified by Gu Xiaolan with efficacy, and he supplemented an internal prescription. He said: "Carpenter Wang, over thirty years old, suffered from Warm Heat stage two. I used Bai Hu Tang (White Tiger Decoction) modified and cured him. He did not take follow-up medicine and went to work; seven days later, fever, aversion to cold, and bilateral foot pain prevented walking. Pulse was large and flooding, but Chi positions were soggy and thin. Knowing it was residual Warm Heat pathogens sinking downward, already a critical state of Jie Zu Feng; I used this formula externally, and internally administered Dao Chi Wu Ling San (Guide Out Redness and Five-Ingredient Alisma Decoction) (replacing Gui Zhi with Nen Sang Zhi five qian, adding Huai Niu Xi three qian, using fresh Che Qian as guide) to clear residual heat. Illness disappeared in three days. Later treated many people, all fully recovered." The "Jie Zu Feng" mentioned here is the same symptom as "Tuo Jue Shang Han" and can be grouped together. Internal and external prescriptions should be promoted to clarify efficacy.