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The above thirty-six tongue appearances are a convenient method for diagnosing Shanghan (Cold Damage) by observing the tongue. One must apply careful attention during clinical practice; doing so ensures that errors will be rare.

[Note by Jie] The aforementioned methods of tongue diagnosis are indeed a convenient approach for diagnosing Shanghan. Speaking from the perspective of tongue regions, the tip corresponds to the Upper Jiao (Upper Burner), the center to the Middle Jiao (Middle Burner), and the root to the Lower Jiao (Lower Burner). The entire tongue corresponds to the Stomach, as does the very center of the tongue; the tip also corresponds to the Heart, the root to the Kidney, the sides to the Liver and Gallbladder, and the periphery to the Spleen. Regarding color and form, white corresponds to the Lung Meridian, crimson (deep red) to the Heart Meridian, yellow to the Stomach Meridian, bright red to the Gallbladder Meridian, black to the Spleen Meridian, purple to the Kidney Meridian, scorched purple with prickles to the Liver Meridian, and bluish-green and slippery also to the Liver Meridian. However, although coating colors have their respective organ affiliations, one must primarily rely on the location. For instance, if a coating appears in a specific region, it indicates pathology of that corresponding meridian. Although the original text's method of differentiating syndromes by tongue observation is concise and comprehensive, it lacks descriptions of various tongues such as purple, blue, and moldy-soy-sauce colored tongues. Even regarding black coatings associated with deficiency-cold, the explanation is insufficient. Therefore, based on the theories of sages past and combined with years of clinical experience, I supplement the following descriptions.

(1) Purple Tongue: A whole tongue appearing purple indicates excess-heat in both the interior and exterior of the Zang-Fu organs. This occurs whenever Shanghan transforms into heat, internal heat steams upward, warm-tonifying medicines are mistakenly taken, or dampness-stagnation results from alcohol and food intake. Only when pale purple is mixed with other colors might it indicate a deficiency-cold syndrome. For example, pale purple with a bluish tint, bluish-purple without coating, moist and slippery, and with a thin, small tongue body indicates Yin syndromes where Cold directly invades the Liver and Kidney meridians; treatment should focus on warming and dispersing. Another presentation is a purple tongue resembling a cooked pig liver covered with a floating, slippery coating; this indicates pathogenic heat has transmitted inward while the exterior syndrome is not yet fully resolved, requiring treatment focused on clearing and resolving. If the whole tongue is lusterless and dark purple without any attached coating, this represents extreme heat mimicking cold, a critical condition where only urgent purgation may occasionally turn danger into safety. If the purple coating has a bluish or gray-black center, this indicates heat damaging the Blood level; mild purgation is indicated. Furthermore, those who suffer from Cold after drinking alcohol, or where Phlegm-Heat has been stagnant for a long time, may also present with purple tongue coatings. One must distinguish between moist and dry tongues and identify the etiology to treat accordingly.

(2) Blue Tongue: Blue is a combination of green and bluish-green, akin to the "three blues" used in dyeing. If the tongue is slightly blue but not covering the whole surface, it signifies rampant pathogenic heat scorching Liver fluids; treatment should focus on pacifying the Liver, extinguishing Wind, and resolving toxicity. If the whole tongue is slippery and greasy with blue patches, it indicates Damp-Phlegm or Phlegm-Fluid transforming into Heat; treatment should focus on clearing and transforming. In cases of Plague or Damp-Warmth where Heat stagnates unresolved and blue coatings appear, treatment should focus on aromatic clearing and draining. If the tongue is smooth and blue without coating, regardless of the syndrome or pulse, it indicates extreme depletion of Qi and Blood, which is considered untreatable. If the center of the tongue is slippery with a blue coating, it indicates pathogenic heat transmitting to the Jueyin Meridian with injury to Yin fluids, also considered untreatable. If a pregnant woman presents with a purely blue tongue, it indicates a dead fetus in the womb, requiring urgent purgation. If the blue color has a coating, it indicates the Zang-Fu organs' Qi levels are damaged by Heat, leading to stagnation of blood in the channels. Symptoms include mania, cursing, alternating crying and laughing, high fever, intense thirst, chest-beating, and astonishment. Treatment requires Shiquan Kuhu Jiubu Tang (Ten Thousand Complete Bitter-Cold Rescue and Tonification Decoction) [see previous section], with doubled doses of Sheng Shigao (Gypsum Fibrosum) and Huanglian (Coptidis Rhizoma), administered urgently.

(3) Moldy-Soy-Sauce Colored Tongue: This color resembles a mixture of yellow, red, and black, indicating inherent organ Heat complicated by retained food. It appears in conditions such as prolonged internal Heat stagnation, excess Heat steaming the Stomach, retained food obstructing the Spleen, Shanghan transmitting to Yin stages, Summerheat causing irritability, abdominal pain with diarrhea or constipation, high fever, and intense thirst. Treatment involves continuous administration of Shiquan Kuhu Jiubu Tang. If the whole tongue is moldy-colored with yellow coating in the center, it indicates accumulation of excess Heat; continuous administration of Dachengqi Tang (Major Order the Qi Decoction) is appropriate. If the moldy color in the center of the tongue is thick and floating, cannot be completely scraped off, or regenerates immediately after scraping, this indicates retained food in the Middle Jiao stagnating and transforming into Heat over time. First use Dachengqi Tang, followed by Sanhuang Baihu Tang (Three-Yellow White Tiger Decoction), administering them alternately and urgently.

(4) Deficiency-Cold Black Tongue: Whenever the tongue is black due to deficiency-cold, it will necessarily be wet, slippery, and without coating. (The mouth is not bitter, lips are not dry, and there is abundant saliva.) There are no cinnabar spots, no prickles, and no fissures. It scrapes clean, resembling a pork kidney soaked in water, with a faint shape. This indicates extreme Cold in the Zang-Fu organs. There are also cases where the whole tongue is black without distinguishing meridians, turning black suddenly from a pale-white state, without passing through a yellow stage. At first glance, it may appear scorched, black, pricky, dry, and cracked, but it scrapes clean and becomes moist when wetted. The lips surrounding the mouth are white, not red or scorched, indicating Cold knotting in the Zang organs. External symptoms may include severe whole-body heat, irritability, aversion to clothing and bedding, and thirst with desire to drink, though intake is small. These resemble excess-heat syndromes, but actually represent extreme Cold in the Middle Jiao with false Heat externally and true Cold internally. However, there must be mental confusion and drowsiness, and the six pulses must be slow, weak, and forceless. Although stool may be constipated, there is an urge to defecate without success. Treatment uniformly focuses on warming and tonifying. Additionally, if the center of the tongue is black without coating, and the tongue base is wet, tender, smooth, and free of spots or lines, this indicates deficiency-cold of the Stomach Meridian. Treatment should employ Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction) added with Rougui (Cinnamon Twig) and Ganjiang (Zingiberis Rhizoma).