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When small black spots appear randomly within the white coating on the tongue, exterior syndrome (Biao Zheng) still exists. Although the condition appears severe, it is appropriate to use Liangge San (Cooling the Diaphragm Powder) to mildly release the exterior. Once the exterior pathogen is resolved, purgation should immediately follow. The formula for purgation is Tiaowei Chengqi Tang (Regulating the Stomach and Resolving Accumulation Decoction).

[Commentary by Jie] When the tongue coating is white with dry prickles in the center, this indicates that warm pathogenic factors have invaded the Hand-Taiyin Lung Meridian. Externally, there will initially be aversion to cold, followed by persistent fever. Although the symptoms seem ominous, treatment should employ acrid-cool clearing and resolving methods. It is appropriate to first use Liangge San (Cooling the Diaphragm Powder) to clear heat from the Upper and Middle Jiao. If the heat subsides but defecation has not occurred, a purgative formula should then be administered. For purgation, Tiaowei Chengqi Tang (Regulating the Stomach and Resolving Accumulation Decoction) is suitable.

When the tongue surface presents as grayish, with two black halos in the center, this indicates that heat pathogens are attacking the Kidney and Mingmen (Gate of Vitality). Urgent purgation is required. Administer Jiedu Tang (Detoxification Decoction) until three to five bowel movements occur. Delay makes treatment difficult. For the initial dose, add Rhizoma et Radix Rhei (Dahuang, 大黄), soaked in wine, and adjust the dosage according to the patient's size.

[Commentary by Jie] A gray tongue color generally indicates a serious condition. If the coating is dry with little fluid, these are all excess-heat interior syndromes without deficiency-cold exterior signs. Examples include warm-dry seasonal epidemics, stagnation accumulated in the chest, blood stasis causing mania, or undigested food retention. If Taiyang disease has been resolved through sweating, yet the tip of the tongue is gray-black, this indicates undigested food retention or residual heat flaring up due to food stagnation. Treatment should utilize Tiaowei Chengqi Tang (Regulating the Stomach and Resolving Accumulation Decoction). If miscellaneous diseases present this tongue sign, Da Chengqi Tang (Major Order the Qi Decoction) combined with Cortex Phellodendri (Huanglian, 黄连) is appropriate. In the current case, where the tongue is gray with two black halos, this belongs to heat toxins spreading through the Three Yin meridians. The treatment method urgently requires draining heat and purging accumulation. One may use Baihu combined with Chengqi Tang, or Shiquan Kuhan Jiubu Tang (Ten-Ingredient Bitter-Cold Rescue and Nourishment Decoction) for urgent purgation. After defecation, Jiedu Tang (Detoxification Decoction) should be used again to clear residual heat. Because the heat toxin has penetrated deeply into the interior, if one considers Jiedu Tang too mild, it must be administered urgently three to five times consecutively, until the gray-black halos completely disappear. For the first administration, add Rhizoma et Radix Rhei (Dahuang, 大黄) soaked in wine. The dosage must be adjusted according to the patient's age. Tongues showing gray-black colors mostly belong to miscellaneous diseases of the Foot-Sanyin meridians, particularly involving the Foot-Shaoyin Kidney and Foot-Taiyin Spleen. Progression from white to yellow, then to gray-black, constitutes a transmitted meridian syndrome; whether accompanied by prickles, dryness, or cracking at the root or tip, urgent purgation is indicated. A deep black halo rising from a pale gray background indicates heat toxins of warm diseases, requiring urgent treatment with formulas such as Liangge San or Shuangjie San to clear heat and detoxify. However, there are cases where repeated sweating and purgation fail to resolve the gray-black coating, and the tongue is moist or neither dry nor moist, with a pulse that is deficient, minute, and powerless. This results from excessive sweating and purgation damaging body fluids. Treatment must prioritize nourishing fluids and generating moisture; one must not recklessly use Natrii Sulfas (Mangxiao, 芒硝) and Rhizoma et Radix Rhei (Dahuang, 大黄).