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If the tongue surface appears red with small black spots, it indicates that heat-toxin has invaded the Stomach due to deficiency. Accumulation of heat leads to the eruption of macules (rash). It is appropriate to use Xuan Shen Sheng Ma Ge Gen Tang (Scrophulariae Radix, Cimicifugae Rhizoma and Puerariae Radix Decoction) or Hua Ban Tang (Macule-Resolving Decoction) to resolve it.

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[Commentary by Jie] If the tongue coating is purely red and prickly, the external symptoms must include restlessness and irritability, deafness, malar flush, and macules appearing on the chest. In severe cases, there may be coma and delirious speech. The treatment should clear the heat of Shaoyang (Lesser Yang) and resolve pathogens in the Ying (Nutritive) level. Alternatively, if the tongue resembles thorns and the macules are purple, with red eyes and a red face, and the patient is listless and mute, Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction) should be used. (Herbs: Rhinoceros Horn [now substituted with water buffalo horn], Sheng Di Huang [Rehmanniae Radix], Mu Dan Pi [Moutan Cortex], Bai Shao [Paeoniae Radix Alba]). Remove Bai Shao, and add Zhi Shan Zhi (Fried Gardenia), Yin Hua (Honeysuckle Flower), and Shi Chang Pu (Acori Tatarinowii Rhizome) to resolve heat in the Pericardium. Regarding the severity indicated by the color of the macules, the former expert Wu Kun'an distinguished them clearly. He said: "For macules and rashes, red indicates Stomach heat; purple indicates severe heat; purple-black indicates rotting of the Stomach. Red macules have a mortality rate of five deaths to five survivals; black macules have nine deaths to one survival. Fresh red macules that are sparse and distinct are not dangerous even if extensive. However, those dense like pinheads, purple-black and conflated, are difficult to treat. Blue and black macules indicate death." Furthermore, according to *She Jian Bian Zheng* (Differentiation of Tongue Diagnosis), the treatment methods for this type of tongue differ significantly. The text states: "A tongue that is purely red with small black spots indicates heat in all zang-fu organs. In Shanghan (Cold Damage), pathogens transmit to the Yangming Fu organs. Due to mismanagement, evil fire forces entry into the Three Yin syndromes. Or epidemic toxins directly attack the Three Yin syndromes. Or patients with excess heat mistakenly take acrid-warm herbs, causing dryness damaging the Three Yin syndromes—all these conditions can present this tongue. Regardless of age, disease, or pulse, upon seeing this tongue, one should immediately use Shi Quan Ku Han Jiu Bu Tang (Ten-Ingredient Bitter-Cold Rescue and Tonification Decoction). (Sheng Shi Gao [Gypsum Fibrosum] 8 liang ground to powder, Sheng Zhi Mu [Anemarrhenae Rhizoma] 6 qian de-haired, Huang Bo [Phellodendri Cortex] 4 qian, Huang Qin [Scutellariae Radix] 6 qian, Da Huang [Rhei Radix et Rhizoma] and Mang Xiao [Natrii Sulfas] each 3 qian, Sheng Chen Pi [Citri Reticulatae Pericarpium] 1 qian, Sheng Zhi Shi [Aurantii Fructus Immaturus] 1.5 qian, Xian Xi Jiao Jian [Tibet Rhinoceros Horn Tip] 4 qian). Double the dose of true Xi Jiao Jian (Rhinoceros Horn Tip). Continuous administration will surely cure. Old theories using Yuan Shen (Scrophulariae Radix), Sheng Ma Ge Gen Tang, and Hua Ban Tang have misled many." However, if the tongue coating has red mixed with purple-black spots, or if external symptoms include macules, it indicates extreme heat in the Heart and Stomach. San Huang Tang (Three-Yellow Decoction) combined with Bai Hu Tang (White Tiger Decoction) should be used with modifications for treatment.

Xuan Shen Sheng Ma Ge Gen Tang is Xuan Shen Sheng Ma Tang plus Ge Gen (Puerariae Radix).

[Commentary by Jie] Sheng Ma (Cimicifugae Rhizoma) has a primary property of ascending and is a specific herb for raising and moving upward. If treating Shanghan where both releasing the exterior and clearing heat were neglected, or when warm-summer pathogens struggle with Stomach heat causing macules, one must prevent rebellious Lung Qi which could lead to wheezing and coughing. Although Ge Gen can stimulate Stomach Qi, raise fluids to quench thirst, and release muscle-layer heat, it is also unsuitable for treating macules. Therefore, the ancient expert Zhu Zhenheng warned: "Once macules and rashes show red spots, Xuan Shen Sheng Ma Ge Gen Tang must not be used, lest the deficient exterior worsen the macule erosion." As for Yuan Shen (Scrophulariae Radix), although it can nourish fluids and resolve macules, using it together with Sheng Ma and Ge Gen is likely like pouring a cup of water on a cartload of burning wood—of no benefit. Thus, *She Jian Bian Zheng* criticizes this approach as having "misled many."

Hua Ban Tang is Bai Hu Tang plus Ren Shen (Ginseng Radix et Rhizoma).

[Commentary by Jie] Zhao Yi-de stated: "Shi Gao (Gypsum Fibrosum) treats heat-fire in the Triple Burner, with effects more focused on clearing the Lungs. It retreats fire from the Lungs, thus serving as the Sovereign herb. Zhi Mu (Anemarrhenae Rhizoma) also clears Heart fire within the Lungs and nourishes the source of Water. Ren Shen (Ginseng Radix et Rhizoma) generates fluids and benefits the damaged Qi, serving as the Minister. Jing Mi (Oryza Sativa) and Gan Cao (Glycyrrhizae Radix et Rhizoma) tonify Earth to assist Metal, serving as the Assistant." From this, we know this formula primarily aims to rescue the Lungs. Although it can also clear Stomach heat and generate fluids, for treating a red tongue with black spots where heat-toxin enters the Stomach causing macules, it is advisable to incorporate methods from Cheng Qi Tang (Order the Qi Decoction).