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The severity of exterior and interior syndromes in Shanghan (Cold Damage) can be largely determined by inspecting the tongue coating. Du Qingbi's thirty-six methods are considered overly complicated. I hereby establish five key categories: white coating, black coating, yellow coating, dry coating, and slippery coating. If the tongue color is normal despite high fever, it indicates exterior heat without interior heat; treatment should focus on the exterior. If a white and slippery coating is observed, the pathogen is at the half-exterior half-interior level and has not entered the interior; harmonization is appropriate. If a yellow coating is seen, heat resides in the Stomach organ system (Wei Jia); if the yellow coating is dry and cracked, heat has entered the interior, requiring clearing of interior heat. If there are indications for purgation, purgative methods may be used. Regarding black coatings, two distinct types must be differentiated: a black, scorched, cracked, hard, and prickly coating indicates extreme interior heat, resembling charcoal from excessive fire; a black coating with moisture, soft, moist, and slippery indicates severe interior cold, resembling water overcoming fire. These five types constitute the main principles of tongue diagnosis, yet symptoms and pulse palpation must still be consulted for confirmation. For instance, although a black, dry, cracked, and prickly coating undoubtedly indicates interior heat, if accompanied by body pain, cold feet, absence of sweating, floating pulse, or hidden pulse, treatment should still address the exterior syndrome. Although acrid-warm herbs are contraindicated, acrid-cool herbs should be used to disperse the exterior before clearing the interior. Overuse of heat-clearing herbs will prevent sweating and fail to resolve the exterior pathogen. Furthermore, if a patient has a coated tongue, thirst but inability to swallow water, and a floating, large, but non-rapid pulse, administering heat-clearing herbs may worsen the condition, leading to delirium and coma. This is often incurable because while tongue coating indicates interior heat and thirst suggests fluid consumption, the pulse should typically be deep and rapid; the contradiction between symptoms and pulse is the cause. However, I propose that if thirst is present but water is not swallowed, and the pulse is slippery and non-rapid, this suggests food stagnation, which can be treated with digestion-promoting methods, sometimes resulting in recovery. Thus, exterior syndromes complicated by food stagnation can also present with prickly tongue coatings. Generally, if the edges of the tongue show defects resembling sawteeth, it indicates an incurable condition.

Inspecting the mouth for dryness or moisture helps determine the exterior-interior severity of Shanghan, but lip inspection is equally important. The lips connect to the Hand and Foot Yangming meridians (Large Intestine and Stomach) and the Hand and Foot Taiyin organs (Spleen and Lung). Therefore, red and lustrous lips indicate no interior heat, suitable for acrid-warm exterior-dispersing treatments. Dry and withered lips indicate existing interior heat, requiring interior clearing. Scorched-black lips with irritability, thirst, and ability to drink water indicate extreme interior heat, warranting formulas such as Liangge San (Cool the Upper Burner Powder). In cases of delirium and mania with dry, scorched lips where cold-natured herbs fail to reduce fever, this indicates food stagnation in the Middle Jiao causing jaundice and fever. Cold herbs fail to resolve stagnation, while acrid dispersants hinder interior heat clearance; thus, Baohe San mixed with Zhuli (Bamboo Sap) and Lubo juice (Radish Juice), or Zhizi Chihui Tang (Gardenia and Fermented Soybean Decoction) plus Chen Zhishi (Aged Immature Bitter Orange) are appropriate. The upper lip corresponds to the Lung and Large Intestine; scorched upper lip with thirst and drinking indicates heat in the upper jiao, primarily affecting the Lung; scorched upper lip without thirst indicates heat in the lower jiao, primarily due to dry feces in the Large Intestine. The lower lip corresponds to the Spleen and Stomach; scorched lower lip with thirst and drinking indicates heat in the Yangming Stomach; scorched lower lip without thirst indicates heat in the Taiyin Spleen. I clarify that whether lip scorching results from interior heat, food stagnation, or latent heat in the blood level is distinguished by thirst and water consumption. However, long-standing food stagnation can generate heat through fermentation, causing thirst and water consumption, necessitating pulse differentiation. A slippery, large, non-rapid pulse indicates unfermented stagnation with no thirst; a slippery, large, deep, and rapid pulse indicates fermented heat with thirst. Therefore, delirium and mania with a slippery, non-rapid pulse, and thirst without water consumption, are treated as food stagnation. Using cold-natured herbs to suppress this will exacerbate delirium and mania, potentially leading to lockjaw and muteness.