（一名刖足伤寒。又名肢脱）。
【因】大约有三。一跣足踏雪后。骤用热水洗足。逼令寒湿深入肢节。二伤寒化热
转燥。渴饮冷水过度。身
不出汗。水气溢入肢节。三农家粪地上。经烈日晒过。赤脚行走。受其毒瓦斯。骤用冷水
洗足。逼令热毒深入肢节。皆足以致肢脱。
【证】初起寒热足肿。状类香港脚。惟皮色紫黯。肢节木痛。继即趾缝流水不止。足
趾肿疼。似溃非溃。即防溃烂堕落。舌苔多起白腐。或黄腐而现黑点。若热毒深入肢节
。两胫多红肿 痛。呻吟啼哭。昼夜不寐。舌多紫红起刺。
【脉】左弦紧。右沉弦而涩者。寒湿或水气下注足胫也。若两尺弦滑搏数者。热毒
留于足胫也。
【治】由于寒湿及水气者。内服大橘皮汤。加生苡仁、鲜车前草（各二两）、杜赤
小豆（一两、三味煎汤代水）。畅利小便以逐水湿。外治先用洗法。（羌活、防风、白
芷、角刺、红花、降香、桂皮、川乌各五钱、川芎、艾叶、樟木片、油松节、桑枝、
葱白各一两、水煎数沸、先淋洗、继擦患处、避风、日洗三次、夜两次、食后洗更宜
、药冷、加开水泡葱白汤和温之、重可转轻、竟有因洗而散者）。次用隔蒜灸法（用独
头大蒜、切片置患处、以艾茸放蒜上灸之、每三壮换蒜。务令不痛者灸至大痛、痛者灸
至不痛、痒者灸至不痒、不痒者灸至极痒为度。若口干烦躁、甚或头项浮肿神昏、不必
疑惧。此阴证转阳、而阳暴回之象、切不可大用凉药、只宜用生绿豆一两、麦冬粳米各
五钱、生甘草一钱、煎汤服之即瘥）又次用掺药法（千年锻石一两、白芷二两、共研细
匀、少许掺之、稠水涌出、出尽即愈）。内外谦治以防其脱脚。七日收功。若热毒蕴伏肢节。
内治以大橘皮汤去桂术。加酒炒防己（二钱）鲜贯众（五钱）、忍冬藤、梗叶、嫩桑枝（各二两先煎代水）。凉通小便以
驱热毒。外治以鸭毛煎汤冲入皂矾（一两）
乘热洗足。日三次。避风。三日即愈。
【秀按】踝下曰足。足背曰跗。（一名足趺、俗称足面。）足后跟曰跟。足指曰趾
。（趾者、别于手也、足之趾节、与手指节同。）其大趾之本节后内侧。圆骨核突者名
核骨。足大趾爪甲后为三毛。毛后横纹为聚毛。足下面着地者为踵。（俗称脚底板）予
所见脱脚一证。有脱一足者。有脱两足者。统称肢脱。有仅脱足趾者。初起色白麻痛。
或不痛者。名脱疽。初起色赤肿痛。如汤泼火烧者。名敦痈。肢脱由秋夏露卧。为寒所
袭。 热内作。搏于肢节。痛彻于骨。遇寒尤甚。以热熨之稍减者。主以大防风汤。（
防风二钱、当归、熟地、生黄 、川杜仲各三钱，党参、白术、羌活、川芎各钱半、淮
牛膝、生赤芍各一钱，淡附片、官桂、清炙草各五分。）肢脱由霉雨湿地。跣足长行。
水气浸淫。留于肢节。隐隐木痛。足跗胖肿。趾缝出水不止者。主以消趺汤。（生米仁
、带皮苓各二两、绵茵陈、泽泻各三钱、酒炒防己、木瓜各一钱、官桂、苍术各钱半。
）脱疽由沉寒痼冷。阴毒搏于趾节。屈不能伸者病在筋。伸不能屈者病在骨。或生于趾
头。或生于趾缝。初虽色白。继则色黑。久则溃烂。节节脱落。延至足背脚跟。白腐黑
烂。痛不可忍。法当内外兼治。外治。以活蟾蜍剖去肝胆肠杂。但用其皮。用线扎缚足
趾以拔毒。内服驱毒保脱汤。（当归一两、 羊胫骨三钱、桂心、生甘草各一钱。黑炮
姜、麻黄、明乳香、净没药各五分。）活血和阳以散其阴毒。敦痈。由湿热下注。亦当
内外兼施。外搽清凉渗湿膏。（用矿锻石化于缸内、次日水之面上结一层如薄冰者、取
起、以桐油对调腻浓、每日搽上二三次、数日全愈、忌食猪肉）。内服仙方活命饮。（
银花五钱、花粉、赤芍各钱半、防风、白芷、广皮、归尾、皂角刺、生甘节、川贝各一
钱，蛤粉、炒穿甲、净没药各八分）。加生淮牛膝（三钱）以解毒壅。如痒痛相兼。破
流黄水。浸淫成片。甚至腿肉浮肿。皆属脾肾亏损。主以补中益气汤加防风、独活。痛
加丹皮、焦栀、炒川柏。兼服六味地黄丸。外以贯众煎汤淋洗。五倍子细末津调。于逐
疮四围涂之。自外收内。每日一
次。渐渐自愈。不可妄投攻发。俞君分别三因。对症发药。殆亦多所经验欤。
【廉勘】脱脚伤寒一症。就外科医治者多。临证三十余年来。从未经验。见诸前哲
方书者亦鲜。惟洄溪老人。载刖足伤寒一案。述嘉善黄姓。外感而兼郁热。乱投药石。
继用补剂。邪留经络。无从而出。下注于足。两胫红肿大痛。气逆冲心。呼号不寐。余
曰此所谓刖足伤寒也。足将落矣。急用外治之法。熏之蒸之。以提毒散瘀。又用丸散内
消其痰火。并化其毒涎。从大便出。而以辛凉之煎剂。托其未透之邪。三日而安。大凡
风寒留于经络。无从发泄。往往变为痈肿。上为发颐。中为肺痈。肝痈。痞积。下为肠
痈。便毒。外则散为 疹疮疡。留于关节。则为痿痹拘挛。注于足胫。则为刖足矣。此
等证俱载于内经诸书。自内外科各分一门。此等证遂无人知之矣。王氏《温热经纬》谓
今人不读《内经》。虽温热暑疫诸病。一概治同伤寒。禁其凉饮。浓其衣被。闭其户牖
。因而致殆者。我见实多。然饮冷亦须有节。过度则有停饮肿满呕利等患。更有愈后手
指足缝出水。速投驱湿保脱汤。（生苡仁、浙茯苓各三两、生白术一两、车前子五两、
桂心一钱。）连服十剂。可免脚趾脱落。此即谚所谓脱脚伤寒也。亦不可不知。沈岷源
《奇证汇云》。一男子患脚跟骨脱落。动之则痛。艰于行步。叶天士先生视之曰。此湿
伤筋络也。以炒苦葶苈四两。炒防己、广木香、茯苓、木通、人参各二钱五分。为末。
枣肉丸如桐子大。每三十丸。桑皮汤下。名圣灵丹。服之果愈。由此三则以观之。一为
痈肿内溃。一为水气下注。一为湿伤足筋。皆足致肢节脱落。而病因各异。治法悬殊。
盖一病有一病之法。医学不可不博也。徐洄溪曰。凡治病各有对证方药。非可以泛治之
方。希图侥幸。但不明理之医。则偏僻固执。又方法绝少。安能肆应不穷。所以动手辄
误。病变日增。而药无一验。即束手无策矣。
【荣斋按】“脱脚伤寒”（严格地说，是∶脱趾伤寒。因所脱的，是趾，不是脚）
。多系病毒下注所致，巢氏《病源论》记载，一为∶“伤寒毒攻足候──此由热毒瓦斯从
内而出，循经络攻于足也。人五脏六腑井荥俞，皆
出手足指，故毒从脏腑而出。”一为∶“伤寒毒流肿候──人阴阳俱虚，湿毒瓦斯与风热
相搏，则荣卫涩，荣卫涩则气血不散，气血不散则邪热致壅，随其经络所生而流肿也。
”这两条，我认为是“脱脚伤寒”之始。它原因是为了“伤寒”而“脱脚”，但病名叫
做“脱脚伤寒”，这种“倒因为果”的说法，中医文献上是屡见不鲜的。吴坤安《伤寒
指掌》所说∶“若发热一身尽痛，而兼四肢微肿者，此风湿流注手足也。宜二陈加米仁
、桂枝、秦艽、防己、羌活、木瓜、片姜黄之类；足胫红肿合二妙。”这条我认为是“
脱脚伤寒”之渐，不过“仅肿未溃”而已。此处强调着“执果溯因”，意在“防微杜渐
”，使患伤寒的不致脱脚。
又按∶王肯堂《医论》载《启东秘旨》说。“温热愈后，余邪往往归之于足，发热
肿痛，不亟治则痛甚而死者多，至轻亦成残废；名曰截足风。今附验方于后∶广胶一两
，入糟、醋、姜、葱汁四味，烊化成膏，摊绵纸或红布上，贴患处，痛立止。（糟入醋
中，将糟捣碎调匀，滤出汁，去糟渣勿用；姜汁不必多，只用少许，葱汁较姜汁多一半
，糟醋须三四倍于葱汁）”此方经顾晓澜实验，都有疗效，并补出一个内服药方。他说
∶“王木匠，年三十余，患温热二候，余用白虎汤加味而瘳。伊芳未服善后药，而赴任务
；七日发热恶寒，两足疼痛不能行。诊其脉洪大，而两尺濡细，知是温热余邪下注，已
成截足风之危候；即用此方外敷，内服导赤五苓散（以嫩桑枝五钱易桂枝，加淮牛膝三
钱，鲜车前为引。）以清余热，仅三日而病如失。后治多人，皆获全瘳。”这里所说的
“截足风”，与“脱脚伤寒”是同一症状，可以归纳在一起。内外方治，应予推展，以
明确疗效。
【病因】大约有三方面。一是赤脚踩雪后，突然用热水洗脚，迫使寒湿深入肢体关节；二是伤寒化热转燥，口渴时过度饮用冷水，身体不出汗，水气溢入肢体关节；三是农民在烈日暴晒过的粪地上赤脚行走，受到毒瓦斯侵害，突然用冷水洗脚，迫使热毒深入肢体关节。这些都足以导致肢体脱落。
【证候】初起时恶寒发热，足部肿胀，症状类似香港脚（足癣/丹毒），但皮肤颜色紫暗，肢体关节麻木疼痛。随后趾缝间流水不止，足趾肿痛，似溃烂非溃烂，需警惕溃烂堕落。舌苔多呈白色腐腻，或黄色腐腻并出现黑点。若热毒深入肢体关节，两小腿多红肿疼痛，患者呻吟啼哭，昼夜无法入睡，舌质多紫红且起刺。
【脉象】左手脉弦紧，右手脉沉弦而涩的，是寒湿或水气下注于足胫所致。若两尺脉弦滑搏动快速，则是热毒留滞于足胫所致。
【治法】由于寒湿及水气引起的，内服大橘皮汤，加生薏苡仁、鲜车前草（各二两）、杜赤小豆（一两，这三味药煎汤代替水煎煮其他药物）。通过通利小便来驱逐水湿。外治先用熏洗法（羌活、防风、白芷、皂角刺、红花、降香、桂皮、川乌各五钱，川芎、艾叶、樟木片、油松节、桑枝、葱白各一两，水煎沸数次，先淋洗，继之擦拭患处，避风，每日洗三次，夜间两次，饭后洗更适宜，药液冷时，加开水泡葱白汤调和温度，重症可转为轻症，甚至有因清洗而消散的）。其次用隔蒜灸法（用独头大蒜切片置于患处，将艾绒放在蒜片上施灸，每三壮更换一片蒜，务必使不痛者灸至感到大痛，痛者灸至不痛，痒者灸至不痒，不痒者灸至极痒为止。若出现口干烦躁，甚至头项浮肿神昏，不必恐惧，这是阴证转阳，阳气暴回的征象，切不可大量使用凉药，只宜用生绿豆一两、麦冬粳米各五钱、生甘草一钱，煎汤服用即可痊愈）。再次用掺药法（千年锻石一两、白芷二两，共研细末均匀混合，取少许撒在患处，待稠水涌出，排尽即愈）。内外兼治以防肢体脱落，七日收功。若是热毒蕴伏于肢体关节，内治以大橘皮汤去掉桂枝、白术，加酒炒防己（二钱）、鲜贯众（五钱）、忍冬藤、梗叶、嫩桑枝（各二两，先煎代水）。通过凉通小便来驱除热毒。外治用鸭毛煎汤冲入皂矾（一两），趁热洗脚，每日三次，避风，三日即愈。
【秀按】踝骨下方称为足，足背称为跗（一名足趺，俗称足面）。足后跟称为跟，脚趾称为趾（趾者，区别于手，足的趾节与手指节相同）。大脚趾本节后内侧，圆骨核突出的地方名为核骨。足大趾爪甲后方有三根毫毛，毫毛后方横纹处为聚毛。足下面着地的部分称为踵（俗称脚底板）。我所见到的脱脚这一病症，有脱落一只脚的，有脱落双脚的，统称为肢脱。有仅脱落脚趾的，初起时色白麻木疼痛，或不痛的，名为脱疽。初起时色赤肿痛，如被开水烫伤或火烧般的，名为敦痈。肢脱是由于夏秋季节露宿野外，受寒气侵袭，热气内生，搏击于肢体关节，疼痛彻骨，遇寒加重，用热敷稍减的，主方为大防风汤（防风二钱、当归、熟地、生黄芪、川杜仲各三钱，党参、白术、羌活、川芎各钱半，淮牛膝、生赤芍各一钱，淡附片、官桂、清炙甘草各五分）。肢脱是由于梅雨潮湿之地，赤脚长途行走，水气浸淫，留滞于肢体关节，隐隐麻木疼痛，足背肿胀，趾缝出水不止的，主方以消趺汤（生薏苡仁、带皮茯苓各二两，绵茵陈、泽泻各三钱，酒炒防己、木瓜各一钱，官桂、苍术各钱半）。脱疽是由于沉寒痼冷，阴毒搏击于趾节，屈伸不能的，病在筋；能伸不能屈的，病在骨。或生于脚趾头，或生于趾缝，初起虽色白，继而色黑，久则溃烂，节节脱落，蔓延至足背脚跟，白腐黑烂，疼痛难忍，应当内外兼治。外治：剖开活蟾蜍，去除肝胆肠杂，只用其皮，用线扎缚脚趾以拔毒。内服驱毒保脱汤（当归一两，羊胫骨三钱，桂心、生甘草各一钱，黑炮姜、麻黄、明乳香、净没药各五分）。活血和阳以散其阴毒。敦痈，是由于湿热下注，也应当内外兼施。外搽清凉渗湿膏（用矿锻石溶于缸内，次日水面结一层如薄冰的物质，取起，用桐油对调至浓稠，每日搽二三次，数日全愈，忌食猪肉）。内服仙方活命饮（银花五钱，花粉、赤芍各钱半，防风、白芷、广陈皮、归尾、皂角刺、生甘草、川贝各一钱，蛤粉、炒穿山甲、净没药各八分）。加生淮牛膝（三钱）以解毒壅滞。如痒痛相兼，破溃流黄水，浸淫成片，甚至腿肉浮肿，皆属脾肾亏损，主方以补中益气汤加防风、独活。痛甚加丹皮、焦栀子、炒川柏。兼服六味地黄丸。外用贯众煎汤淋洗，五倍子细末用唾液调和，涂于疮口四周，由外向内收敛，每日一次，渐渐自愈，不可妄投攻伐发散之药。俞君分别三种病因，对症用药，大概也是多有经验的吧。
【廉勘】脱脚伤寒这一病症，多由外科医生医治，临证三十余年来，我从未见过。见于前人医书中的也很少。只有洄溪老人记载了一例刖足伤寒案，叙述嘉善黄姓患者，外感兼郁热，乱投药石，继用补剂，邪气留滞经络，无从排出，下注于足，两小腿红肿剧痛，气逆冲心，呼号不寐。我说这就是所谓的刖足伤寒，脚即将脱落了，急用外治法，熏蒸以提毒散瘀，又用丸散内消痰火，并化解毒涎，从大便排出，并用辛凉煎剂托透未透之邪，三日而安。大凡风寒留滞经络，无从发泄，往往变为痈肿，上部为发颐，中部为肺痈、肝痈、痞积，下部为肠痈、便毒，外部则散发为疹疮疡，留滞于关节则为痿痹拘挛，注于足胫则为刖足。这些证候都记载于《内经》等书中，自从内外科各自分为一门后，这类证候就无人知道了。王氏《温热经纬》说今人不读《内经》，虽然温热暑疫诸病，一概按伤寒治疗，禁止凉饮，加厚衣被，关闭门窗，因而致死的，我见实在很多。然而饮冷也须有节制，过度则有停饮、肿满、呕吐、腹泻等病患。更有愈后手指足缝出水，速投驱湿保脱汤（生薏苡仁、浙茯苓各三两，生白术一两，车前子五两，桂心一钱）。连服十剂，可免脚趾脱落。这就是谚语所说的脱脚伤寒，也不可不知。沈岷源《奇证汇》云：一男子患脚跟骨脱落，动则痛，行走艰难。叶天士先生诊视说：这是湿伤筋络。用炒苦葶苈四两，炒防己、广木香、茯苓、木通、人参各二钱五分，研为末，枣肉丸如梧桐子大，每服三十丸，桑皮汤送下，名为圣灵丹，服用果然痊愈。由此三例来看，一为痈肿内溃，一为水气下注，一为湿伤足筋，都足以导致肢节脱落，而病因各异，治法悬殊。盖一病有一病的治法，医学不可不博学啊。徐洄溪说：凡治病各有对症方药，不可以泛治之方希图侥幸。但不明理之医，则偏僻固执，方法极少，怎能应对无穷变化？所以动手辄误，病变日益增加，而药无一验，便束手无策了。
【荣斋按】“脱脚伤寒”（严格地说，应是：脱趾伤寒。因为脱落的，是趾，不是脚）。多系病毒下注所致。巢氏《诸病源候论》记载，一为：“伤寒毒攻足候——此由热毒瓦斯从内而出，循经络攻于足也。人五脏六腑井荥俞，皆出手足指，故毒从脏腑而出。”一为：“伤寒毒流肿候——人阴阳俱虚，湿毒瓦斯与风热相搏，则营卫涩，营卫涩则气血不散，气血不散则邪热致壅，随其经络所生而流肿也。”这两条，我认为就是“脱脚伤寒”的起源。它的原因是为了“伤寒”而“脱脚”，但病名叫做“脱脚伤寒”，这种“倒因为果”的说法，中医文献上是屡见不鲜的。吴坤安《伤寒指掌》所说：“若发热一身尽痛，而兼四肢微肿者，此风湿流注手足也。宜二陈加米仁、桂枝、秦艽、防己、羌活、木瓜、片姜黄之类；足胫红肿合二妙。”这条我认为就是“脱脚伤寒”的发展阶段，不过是“仅肿未溃”而已。此处强调“执果溯因”，意在“防微杜渐”，使患伤寒的不致脱脚。
又按：王肯堂《医论》载《启东秘旨》说：“温热愈后，余邪往往归之于足，发热肿痛，不亟治则痛甚而死者多，至轻亦成残废；名曰截足风。今附验方于后：广胶一两，入糟、醋、姜、葱汁四味，烊化成膏，摊绵纸或红布上，贴患处，痛立止。（糟入醋中，将糟捣碎调匀，滤出汁，去糟渣勿用；姜汁不必多，只用少许，葱汁较姜汁多一半，糟醋须三四倍于葱汁）”此方经顾晓澜实验，都有疗效，并补出一个内服药方。他说：“王木匠，年三十余，患温热二候，我用白虎汤加味而治愈。他未服善后药，而去执行任务；七日发热恶寒，两足疼痛不能行。诊其脉洪大，而两尺濡细，知是温热余邪下注，已成截足风之危候；即用此方外敷，内服导赤五苓散（以嫩桑枝五钱易桂枝，加淮牛膝三钱，鲜车前为引。）以清余热，仅三日而病如失。后治多人，皆获全愈。”这里所说的“截足风”，与“脱脚伤寒”是同一症状，可以归纳在一起。内外方治，应予推广，以明确疗效。
(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.