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If the tongue coating is black, but there is no abdominal distension or pain, and the mental state is not severely confused, all are suitable for treatment with "strengthening water and nourishing yin" (Zhuang Shui Zi Yin), and should not be considered as yang deficiency. If the tongue coating is black, appearing dry and prickly to the eye, yet the patient drinks little despite thirst, or has no thirst, and the edges may have white coating while the tongue body itself is pale and moist, this also belongs to false heat; treatment should employ warming and tonifying methods. If the center of the tongue has no black coating, but the root has black coating that is dry, purgative methods are suitable, indicating heat in the lower jiao. If the tongue body has no coating, only the tip is black and dry, this is "heart fire self-burning" (Xin Huo Zi Fen) and is incurable. The above Chapter 12 was moved to Chapter 14 in the Tang edition; it is now corrected. If the tongue is black and slippery, it represents water overcoming fire, belonging to a yin syndrome, and should be treated with warming. If tongue shortening is observed, this indicates exhaustion of kidney qi, which is difficult to treat. To attempt rescue (Tang edition reads "only"), add Ren Shen (Ginseng Root) and Wu Wei Zi (Schisandra Fruit); one may hope for a slim chance (Tang edition reads "or rescue"). If the tongue is black and dry, it signifies fluid exhaustion and blazing fire; urgently clear southern fire (clear heart fire) and supplement northern water (nourish kidney yin). If (the Tang edition adds the character "black" here) it is dry with a thick, concentrated coating at the center (absent in Tang edition), it indicates earth dryness and water exhaustion; urgently use salty and bitter purgatives.

He Baozhi stated: In summer-heat syndromes complicated by blood involvement, many present with a black and moist center of the tongue; do not mistakenly treat this as a yin syndrome.

For black coating presenting with deficiency-cold, only Guizhi Tang (Cinnamon Twig Decoction) and Fuzi (Prepared Aconite Root) are effective, assisted by formulas regulating and tonifying qi and blood, applied according to circumstances. If the coating is black, dry, and absent, there is no turbid pathogen in the stomach.

Wang Shixiong's note: It is not that there is no coating, merely that it is not thick or concentrated.

Therefore, one should clear southern fire and supplement northern water; Zhang Zhongjing's Huanglian Ejiao Tang (Coptis and Donkey-Hide Gelatin Decoction) is the primary formula. If black and dry with a thick concentration at the center, it is turbid pathogenic heat knotting in the stomach; use salty and bitter purgatives like Xiaoshi (Sodium Sulfate) and Dahuang (Rhubarb Root and Rhizome).

Wang Shixiong's note: The above Chapter 13 was moved to Chapter 15 in the Tang edition; it is now corrected. These two chapters discuss the differentiation of black coating syndromes and treatments.

Furthermore: Mao Yuren said: Whenever onset involves fever and chest oppression, with the entire tongue black and moist, and no dangerous external symptoms, this indicates latent phlegm in the chest and diaphragm. There is no need for alarm; simply use Xie Bai (Macrostemon Rhizome), Gualou (Trichosanthes Fruit), Guizhi (Cinnamon Twig), and Banxia (Pinellia Tuber) in one dose, and the black coating will recede. Alternatively, omitting Guizhi and using Zhi Qiao (Aurantium Fructus) and Jiegeng (Platycodon Root) is also effective.

If the tongue is pale red without color, or dry and lacking luster, it indicates injury to stomach fluids where qi cannot transform into fluids; Zhigancao Tang (Licorice Decoction) should be used. Cold-cooling medicines must not be used.

He Baozhi stated: Tongue red and tender like new growth, appearing moist but actually suffering from extreme dryness and thirst, results from reckless sweating and purging, leading to fluid exhaustion.

Pale red without color indicates inherent deficiency of heart and spleen qi and blood. Added dryness and lack of luster indicate loss of stomach fluid qi and yin. Therefore, bitter-cold medicines are contraindicated. Zhigancao Tang nourishes qi and blood to unblock meridians, allowing pathogens to gradually dissipate.

Wang Shixiong's note: The above Chapter 14 was moved to Chapter 11 by Tang; it is now corrected. This chapter discusses cases where deficiency outweighs pathogen, with such tongue colors, emphasizing prioritizing the cultivation of qi and fluids.

If the tongue coating is white like powder and slippery, with purple-crimson edges, this indicates warm epidemic disease entering the membrane source (Mo Yuan) but not yet returning to the stomach fu organ. Urgently resolve and vent it; do not wait for transmission and sinking into dangerous pathology. Moreover, seeing this tongue indicates a severe prognosis, requiring caution. When macules and papules first appear, one must illuminate the chest, back, and hypochondrium with a paper torch. Large spots on the skin surface are macules (Ban); faint cloud-like patterns or tiny granular spots are papules (Zhen). They should appear but not excessively. According to medical texts, red macules belong to stomach heat, purple indicates extreme heat, and black indicates rotting stomach tissue; however, external signs must be combined for diagnosis.

In warm epidemics, thick white coating like accumulated powder indicates heavy turbidity; if the tongue body is purple-crimson, pathogenic heat is closed by turbidity, necessitating urgent resolution. This is damp-warm epidemic among the five epidemics; Keyi's Zhaoyin Yin (Origin-Reaching Decoction) can be used as the main formula, but must be modified according to symptoms; do not adhere rigidly. Purple-crimson tongue body indicates heat closing the Ying level, often resulting in macules and papules. Macules emerge from muscles and belong to the Stomach; papules emerge from blood collaterals and belong to the Meridians. If both appear simultaneously, both meridian and stomach are hot. However, pathogens usually enter the stomach from the membrane source; if accompanied by wind-heat entering meridians, papules occur. Absence indicates pathogen closure, so appearance is favorable. Excessive appearance indicates heavy pathogen, so it is unfavorable. However, macules and papules have excess and deficiency distinctions; failing to distinguish them can be fatal. Thus, the master differentiates as follows.

Wang Shixiong's note: In warm-heat diseases, if the tongue is crimson with widespread white coating, clearing and purifying Lung and Stomach is appropriate. If latent phlegm is abundant causing mental confusion, resolving phlegm is the treatment. Black and blue macules can also be treatable. My cases of Hu Jiquan and Yao Lu are recorded in the Continuation. The case of Xu Yueyan's wife is attached to my great-grandfather's "Random Notes."

However, during spring and summer, damp diseases manifesting as papules are severe, and their color must be distinguished (absent in Tang edition). If pale red, limbs are cool, mouth is not very thirsty, and pulse is not flooding and rapid, these are either deficiency macules or yin macules. If a few points appear slightly on the chest, face is red, feet are cold, or there is diarrhea with undigested food, this is yin excess repelling yang upward, manifesting externally; warming treatment is required.

This specifically discusses macules and papules, not exclusive to warm epidemics, highlighting distinct excess and deficiency types. Fire must be constrained to form macules and papules. If deficiency leads to weak fire, pale color, and cool limbs, it is slight cold. Mouth not very thirsty, pulse not flooding/rapid proves non-excess fire, hence "deficiency macules." If face red, feet cold, diarrhea with undigested food, this is yin-cold excess repelling yang outward, internal true cold, external false heat, constrained into macules, hence directly named "yin macules." Must use Fuzi (Prepared Aconite Root) and Guizhi (Cinnamon Twig) to guide fire back to its source; misusing cooling drugs causes death. Misusing tonics for excess fire also causes death; careful differentiation is crucial.

If macules are purple (Tang edition adds "and") small dots, it is Heart Pericardium heat. Large purple dots indicate Stomach heat. Black macules that are bright/lustrous indicate heat prevailing and toxin flourishing (Tang edition reads "heat extreme, toxin blazing"). Although considered incurable, if the patient has sufficient qi and blood, following proper treatment may save them. If black and dull, death is certain. If black and faint with surrounding redness, it is fire constrained internally; large doses of cooling and venting agents may occasionally turn red and become salvageable. If macules and papules mix, it indicates diverse pathogens, each draining according to their location. Macules mostly relate to blood; papules often relate to qi. Both are manifestations of pathogens emerging externally. Upon emergence (Tang edition adds "at the time"), mental clarity indicates exterior resolution and interior harmony. If confusion persists after emergence, righteous qi fails to overcome pathogens, leading to internal sinking, or due to internal depletion of stomach fluids.

This discusses excess-fire macules and papules. Small dots emerging from blood collaterals are papules, thus heat in Heart Pericardium; large dots emerging from muscles are macules, thus heat in Stomach. Black and bright indicates residual yuan qi, possibly salvageable; dark/black indicates yuan qi failure, certain death. Surrounding redness indicates active qi and blood, allowing venting. Mixed macules/papules involve meridian/stomach heat draining externally. Heat entering stomach belongs to Qi level; seeing macules implies pathogen relates more to Blood. Papules emerge from blood collaterals, originally Blood level, but formed when Qi pathogen blocks Blood; thus, clearing both Qi and Blood is necessary. Confusion after emergence means righteous qi loses to pathogen, leading to death.

Wang Shixiong's note: The above Chapter 15 details differences in macule/papule treatment in warm epidemics; Tang moved it to Chapter 16; now corrected.

Another type is Bai Bo (white papules), small grains like crystal color. Yang Yun said: Healthy people occasionally get them in summer. This is damp-heat injuring Lung; although pathogen exits, qi and fluids are exhausted; sweet-tonics are required. Or, if not prolonged to injure qi/fluids, it is damp constraining the Wei level, incomplete sweating; regulate Qi level pathogen. If Bai Bo looks like dead bone, prognosis is poor, indicating qi/fluid exhaustion.

Wang Shixiong's note: Damp-heat constrained in Qi level, missed by light-clearing venting,幸 avoiding other meridians, emerging as Bai Bo from Wei level; treat by clearing residual Qi pathogen. If pathogen constraints long, even if transforming into Bai Bo, qi/fluids drain; thus sweet-moistening tonification is needed. If color is white like dead bone, even sweet tonics may fail. The above Chapter 16 was moved to Chapter 17 by Tang; now corrected.

Yang noted: Those with inherent damp-heat abundance often show this; in warm diseases, it is mild, without other complications. Having never seen Bai Bo like dead bone, I dare not speculate.

Wang noted: Bai Bo was not discussed in detail by predecessors; this section is valuable. I have seen Bai Bo like dead bone; not only incurable, but too late to save. Thus, vulgar doctors frighten families upon seeing Bai Bo. Actually, crystal-colored Bai Bo is insignificant; I have seen many. However, not knowing sweet-moistening methods, instead using bitter-dry ascending drugs, turns non-exhausted into exhausted.

Regarding warm-heat diseases, after examining the tongue, teeth must also be checked. Teeth are the surplus of Kidney; gums are the network vessels of Stomach. Pathogenic heat not drying stomach fluids will consume kidney fluids; blood of both meridians flows to these areas. Deep disease moves blood, forming petals on top. Yang blood is purple, like dried lacquer; Yin blood is yellow, like soybean paste. Seeing Yang blood, prioritize calming Stomach; seeing Yin blood, prioritize saving Kidney. However, soybean-paste color is dangerous; if symptoms are not adverse, treatable; otherwise difficult. Why? Because yin exhausts below, yang reverses above.

Kidney governs bones; teeth are bone surplus. Floating teeth with non-swollen gums indicate kidney fire/water deficiency. Stomach network vessels connect to upper gums; Large Intestine network vessels connect to lower gums; both belong to Yangming. Thus, gum swelling/pain is Yangming fire. If damp enters Stomach, it affects Large Intestine; blood flows through collaterals, pathogenic heat moves blood upward to gums. Purple is Yangming blood, clearable/purgable. Yellow is Shaoyin blood; Shaoyin blood injury is lower exhaustion, with yang pathogen rising and qi reversal, making it difficult.

Wang Shixiong's note: The above Chapter 17 was moved to Chapter 18 by Tang; now corrected.

If teeth are shiny and dry like stone, stomach heat is severe. If no sweat and aversion to cold, Wei level dominance; pungent-cool venting Wei to induce sweat is key. If like dead bone color, kidney fluid exhaustion, difficult to treat. If upper half moist, water does not ascend, heart fire flares upward. Urgently clear heart and save water; wait for dry area to become moist.

Severe stomach heat with aversion to cold indicates internal yang constraint and blocked exterior qi, causing no sweat and Wei dominance; vent Wei to induce sweat, dispersing internal heat via exterior. Aversion to cold with sweat indicates exterior yang deficiency and insecure pores; even with internal heat, it is not excess fire. Dry teeth with shine indicate stomach fluid dry but kidney qi intact. Like dead bone indicates kidney failure, hence difficult. Upper half moist nourished by stomach fluid. Lower half dry because kidney water cannot nourish roots, while heart fire burns; urgently clear heart and save water; Zhang Zhongjing's Huanglian Ejiao Tang (Coptis and Donkey-Hide Gelatin Decoction) is indicated.

Teeth grinding/chattering indicates damp-heat transforming into wind, spasm disease. Only grinding indicates stomach heat moving through collaterals. Grinding with deficient pulse/symptoms indicates stomach deficiency lacking grain to nourish; also grinds. Why? Deficiency prefers excess. Tongue stiff but not shortened, jaw locked hard open: not wind-phlegm blocking collaterals, but impending spasm; rub with sour substance to open, as Wood drains Earth.

Teeth gnashing indicates internal wind stirring. Only biting without gnashing indicates excessive heat filling collaterals, jaw tension. If pulse/symptoms deficient, stomach lacks grain, internal wind attacks collaterals via deficiency, causing grinding; deficiency showing excess signs, termed "deficiency prefers excess," requires careful differentiation. Wind-phlegm blocking collaterals is excess; heat transforming into wind impending spasm, or yin-injury with deficiency, all require differentiation.

Wang Shixiong's note: The above Chapter 18 was moved to Chapter 19 by Tang; now corrected.

Tooth plaque like gray cake indicates stomach qi powerless, fluid loss, damp-turbidity dominating; mostly fatal. Early stage bleeding from tooth gaps with pain indicates stomach fire rushing; painless indicates dragon fire internal burning. Teeth scorched without plaque: death. Teeth scorched with plaque: kidney heat, stomach plundered. Mild purgation or Yuniu Jian (Jade Woman Decoction) to clear stomach and save kidney is suitable.

Tooth plaque forms from kidney heat steaming stomach turbidity; gray cake color indicates decay, fluid/qi exhaustion, kidney/stomach dual exhaustion, only damp-turbidity remaining, hence fatal. Bleeding from gaps due to stomach fire comes from gums, painful due to rushing; painless comes from tooth roots, painful due to kidney fire rising. Scorched teeth indicate kidney water exhaustion; no plaque indicates stomach fluid exhaustion, hence death; with plaque indicates fire strong but qi/fluid not exhausted. Assess severe heat, mildly purge stomach heat with Tiaowei Chengqi Tang; assess kidney water deficiency, clear stomach/nourish kidney with Yuniu Jian.

Wang Shixiong's note: The above Chapter 19 was moved to Chapter 20 by Tang. These three chapters discuss diagnosing warm-heat via teeth/mouth. This reveals previously unpublished secrets beyond tongue coating, serving as future guidelines. Readers applying this analogically will recognize more than just warm diseases.

Women contracting warm diseases are similar to men, but often involve pre-natal/post-natal states or menstruation starting/stopping. Ancient texts generally used Siwu Tang (Four Substances Decoction) modifications for pre-natal illness, emphasizing protecting the fetus to prevent harm, e.g., using well-bottom mud or cold-soaked blue cloth on abdomen for extreme heat. All aim to protect, but must assess if pathogen can be resolved. If blood-nourishing greasy drugs fail, re-evaluate; do not apply rigid rules. Step-by-step protection of fetal origin is needed to prevent righteous qi damage and pathogen sinking.

Protecting fetal origin means preventing pathogenic heat from injuring fetus internally. If pathogen is still at Wei level, resolve externally via opening/dispersing; adhering strictly to Siwu Tang would draw pathogen inward, worsening mild disease. Yang Yun: This explanation is clear. Determining treatment based on pathogen depth is essential. If pathogenic heat forces fetus, urgently clear internal heat; external mud/cloth cover might drive heat inward, harming fetus; examine carefully, do not use lightly. Generally, clearing heat/resolving pathogen without injuring fetus constitutes protection. Assisting qi to reach pathogen can be酌情 used. Blood-nourishing greasy drugs may hinder pathogen.

Wang Shixiong's note: This view is correct but focuses on drugs rather than disease. If warm-heat scorches Ying-yin, Dihuang (Rehmannia Root) is usable. Also, *Neijing* states: "Pregnant woman, poison how? Qibo: With cause, there is destruction, also no destruction. Major accumulation/depression, can be attacked, reduce by more than half then stop, do not exceed." Thus, Yangming excess heat in cold damage also uses Chengqi purgation; pathogen removal ensures fetal safety. Pathogen shallow in meridians, deep in fu organs; fetus tied to zang organs. Attacking meridians/fu organs directs drug action to pathogen, sparing zang organs.

Wang Shixiong's note: This interpretation is thorough, yet forgets warm-heat transmitting to Ying/Blood levels. Text says "do not apply rigid rules," not that blood drugs are unusable. Recklessly using tonics to close pathogen harms fetus. If pathogen enters zang organs, even without drugs, fetus perishes and life endangered.

Wang Shixiong's note: Must discuss which zang organ pathogen enters. Hence scripture says "with cause no destruction," meaning if pathogen hasn't entered zang, attacking pathogen won't destroy fetus. Yang Yun: "With cause no destruction" means disease bears the impact. No need to add "pathogen not in zang" to confuse. Crucial is clear differentiation and proper method; Siwu Tang alone cannot protect fetus. Master said: "Assess if pathogen can be resolved, do not apply rigid rules." Profound words!

Regarding post-natal methods, texts advise caution with bitter-cold to avoid injuring already lost yin. However, differentiate if pathogen can resolve via upper/middle; slight symptomatic use is acceptable. Just avoid Lower Jiao. Since constitution is deficient, treat like weak person with pathogen. Overall, do not violate prohibitions against reinforcing excess or depleting deficiency. Post-natal period features boiling qi/blood, many empty spaces; pathogen inevitably sinks via deficiency; treating deficiency-receiving-pathogen is difficult.

Wang Shixiong's note: Refer to my medical records for post-natal warm-heat treatments; omitted here.

Xu Huixi said: Post-natal blood loss leaves lone yang rampant; even if Shigao (Gypsum) and Xijiao (Rhinoceros Horn - substitute with Buffalo Horn) are indicated, they are not forbidden. Yet vulgar doctors, believing post-natal warmth theory, use pungent-hot drugs regardless of condition, damaging yin and boosting fire, causing immediate death. I have seen much; Ye Tianshi's cases lack this flaw, proving profound learning.

Wei Liuzhou said: Recent specialists and quacks treat post-natal solely with dry-hot tonics, killing like flies.

Wang Shixiong's note: Even without warm-heat pathogen, this happens; what about with warm-heat?

Wu Jutong said: Post-natal warm disease, though treating upper avoids middle, drugs shouldn't be too light. Use "prepare much, take little" method; stop when hitting target. Like an army without supplies, favoring quick battle. Fear of post-natal weakness leading to light dosing delays treatment; by day 3-4, body cannot tolerate drugs.

If menstruation starts/stops, pathogen will sink into Blood Chamber (Xue Shi). Shaoyang cold damage discusses this thoroughly; no need to repeat. But frequent movement differs from standard cold damage. Zhang Zhongjing established Xiaochaihu Tang (Minor Bupleurum Decoction) to extract sunk heat; Renshen (Ginseng) and Dazao (Jujube) support Stomach qi, as Chong Mai belongs to Yangming. This suits deficiency. If heat sinks and knots with blood, follow Tao's modification of Xiaochaihu Tang: remove Renshen/Dazao, add Shengdi (Rehmannia Root), Taoren (Peach Kernel), Shanzha (Hawthorn Fruit), Mudanpi (Moutan Bark), or Xijiao (Buffalo Horn). If meridian blood knot is severe, lower abdomen full/painful. Mild: puncture Qimen (LR14). Severe: Xiaochaihu Tang remove sweet herbs, add Yanhu (Corydalis Rhizome), Guiwei (Angelica Root Tail), Taoren (Peach Kernel). With cold: add Rouguixin (Cinnamon Heart). Qi stagnation: add Xiangfu (Cyperus Rhizome), Chenpi (Tangerine Peel), Zhike (Aurantium Fructus). Shen Yueguang used Chaihu (Bupleurum Root), Qinjiao (Gentiana Macrophylla Root), Jingjie (Schizonepeta Spike), Xiangfu (Cyperus Rhizome), Sugeng (Perilla Stem), Houpo (Magnolia Bark), Zhike (Aurantium Fructus), Danggui (Angelica Sinensis Root), Xiong (Ligusticum Rhizome), Yimucao (Leonurus Herb), Mutong (Akebia Stem), Huangqin (Scutellaria Root), named He Xue Zhu Xie Tang (Harmonize Blood Expel Pathogen Decoction). Add small amount of Jiangyi (Ginger Skin) as guide. Effective for cold damage heat sinking into Blood Chamber with qi stagnation/blood stasis causing chest/abdominal fullness/pain. However, heat sinking into Blood Chamber often presents with delirium/raving; prevent similarity to Yangming Stomach excess (Tang edition adds "similar to Yangming Stomach excess" and "this pathogenesis"). Differentiate carefully (Tang edition reads "must distinguish most"). Blood knot causes heavy body, unlike Yangming's agility. Why? Yin governs heaviness/turbidity; collaterals blocked, side qi paralyzed, connecting chest/back stiffness/immobility (Tang edition reads "all obstructed"). Thus expelling pathogen/unblocking collaterals fits disease. Often prolongs, reversing to Heart Pericardium, chest pain (Tang edition adds "bi"), i.e., Tao's "Blood Knot Chest". Wang Haicang proposed Guizhi Honghua Tang (Cinnamon Twig and Safflower Decoction) plus Haige (Concha Arcae) and Taoren (Peach Kernel), originally resolving exterior-interior, upper-lower simultaneously.