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Mangci (thorny projections) appear on the tongue coating, and the throat is dry as if roasted. This is a difficult syndrome seen in Shanghan (Cold Damage diseases), representing the image of Yang excess and Yin consumption. However, by supporting Yin and benefiting Yang, the danger can be resolved. If seen in Douzhen (smallpox or measles), it is generally due to the rampant action of fierce toxins, not merely simple scorching heat. In severe cases, the tongue becomes dry, scorched, and black daily, primarily due to toxic accumulation blocking the throat, resulting in hoarseness, choking on water, and inability to speak. If the thorns on the tongue are like coal, indicating an untreatable condition where one seeks to resolve the crisis, non-cold-cooling purgation is indispensable. Even if attack and resolution are required, plans must be made early during the time of recovery. The main herbs used are Dahuang (Rhei Radix et Rhizoma), Gualou Ren (Trichosanthis Semen), Shigao (Gypsum Fibrosum), and Zhike (Aurantii Fructus).

Hoarseness is caused by Lung Heat; there are cases of Fei Wei (Lung萎/Atrophy), and cases where Wind-Toxin enters the Lung. Hoarseness can be due to Fire Depression, and the tongue may show signs of Phlegm Confusion.

The Heart is the master of voice; the Dantian (Elixir Field) is the residence of voice; the Hou (Throat) is the gate of voice. When subjected to heat-toxin simmering, excessive heat generates phlegm, body fluids become sticky and bound, and phlegm-toxin fills and obstructs. This hinders the Lung Orifices and the airway, preventing the toxin from fully dispersing to the muscle surface, thus causing hoarseness. Since the heat-toxin no longer moves outward, leading to obstruction of the Lung Orifices, even though the voice has its root and master, it cannot resonate. Furthermore, Metal (Lung) sounds because it is hollow; if not hollow, it does not sound. It is appropriate to use Li Zi (Camelliae Seed), Jiegeng (Platycodonis Radix), Huafen (Trichosanthis Radix), Gancao (Glycyrrhizae Radix et Rhizoma), Changpu (Acori Tatarinowii Rhizoma), Huangqin (Scutellariae Radix), Maidong (Ophiopogonis Radix), Zhimu (Anemarrhenae Rhizoma), Gouding (Uncariae Ramulus cum Uncis), Chuanbei (Fritillariae Cirrhosae Bulbus), Tianma (Gastrodiae Rhizoma), Qianhu (Peucedani Radix), and Shaoyao (Paeoniae Radix) to clear the fire and smooth the phlegm, so that the Lung opens and the voice emerges. If hoarseness and sweating occur after prolonged diarrhea, it indicates Yuanqi (Original Qi) collapse; do not treat the phlegm. If hoarseness occurs at the beginning of Douzhen, but the patient remains calm with normal diet and appetite, this is auspicious. If hoarseness and loss of voice occur during the eruption stage, accompanied by teeth grinding, chills, restlessness, coma, dry retching, choking on water, Suohou (Lock Throat/stridor), phlegm obstruction with rapid breathing, incessant diarrhea, abdominal distension with confusion, these are all ominous signs. Changes occurring before the voice appears indicate Bi Yu Bing (Exterior Stagnation Disease); changes occurring after the voice appears indicate Ge Re Bing (Diaphragmatic Heat Disease); voice failing to emerge after eruption indicates simultaneous Exterior and Diaphragm disease. Coughing with voice emission is not included in this category. At this time, Beishashen (Glehniae Radix) can also be used to clear the Lung; when the Lung consolidates, the voice opens. Only after the rash has receded for over a month should Hezi (Terminalia Chebulae Fructus), Ejiao (Colla Corii Asini), and Nuomi (Oryzae Glutinosis Semen) be used.