温热之邪，初入肺卫，治以银翘散时，不可因初起病轻而忽略兼夹。必须详审病情，随症适当加减，方能见效。如初起恶寒，可将芦根易葱白，或将芥穗适当增量，再辅以防风，酌情采用。如无恶寒，芥穗即可不用。咳者，牛蒡子、桔梗适当增量。热甚者，又当辨其性质，如燥热甚加石膏、知母；湿热有火则加黄芩之类。温病初起，治宜清凉辛散，最易忽略兼夹恶寒，须要配以温散的一面。只有细察之，并随症加减，庶几面面周到，用药必然有效，否则虽不致一下坏事，但亦能迁延病机，损耗津液，成为以后变证的因素。这是需要引起高度注意的。
温病重在辨舌
温病化燥伤阴最速，表现在舌的方面最为显著，通过舌诊可以辨别受邪的浅深，疾病的轻重，津液的存亡，所以李老在诊治温病时非常注重辨舌。他认为舌的症状主要表现在舌苔、舌质及舌的感觉等方面，而且辨舌应该结合患者的兼见症状，综合分析辨证，进而提出治法及方剂。
现将李老对舌诊的论述总结于下：
一、舌质
(一)红舌
凡见红舌，均系热证，凡温热病初起，舌质深红者都是伏气温病，因为郁热在里的缘故。
1．舌尖红赤起刺，系心火上炎，治宜清凉泻火。
2．舌红中有裂纹如人字形者，系心火内燔，热毒熏蒸。
3．舌红中有红点者系热毒更盛。
以上二证均可于清凉泻火中加入解毒药品。
4．舌质光红柔嫩，望之似觉潮润，扪之干燥无津者名镜面舌，系津液枯竭的现象，温病后期多见此舌。
5．舌淡红无色，干而不荣者，系心脾气血虚弱，胃津已伤，气不化液之证，用药不可过于寒凉，可仿炙甘草汤法治之。
6．舌四边色红，中心干燥，兼黄白苔者，系上焦气分无形之邪热灼伤津液，切忌早用咸寒滋腻血分的药品，以免邪不外解，有误病机。
7．红舌兼黄白苔者，系上焦气分之邪未尽，不可早用滋腻血分之药。
(二)绛舌
绛，系红色之深者，舌色由红而绛，乃热邪深入，由营分入血分的主要表现，以苔之有无，色之深浅、鲜晦，质之燥润、荣枯为辨证的准则。但必须结合其他营分血分的症状方能准确辨证。
1．舌绛而不干燥，兼有黄白苔者
系邪入营分血分，而气分之邪未尽，滓液未伤。治宜宣气透营，使邪仍由气分而解，不可单纯用凉血药，因血药滋腻，易致邪气遏伏，不能外透。
2．舌纯绛无苔，色鲜泽者
乃舌苔尽化，邪已人营血。治宜清营凉血。若邪入心包络则神昏内闭，治宜清心开窍，轻者用菖蒲、郁金开之，重者用牛黄丸、至宝丹、紫雪丹芳香开窍；若兼火痰，必致痰火内闭，更当加西黄、川贝、竹沥、竺黄之类清火豁痰。
3．舌绛，兼有粘腻，似苔非苔现象者
乃营分有热，夹秽浊之气也。治宜清泄营热，兼用芳香逐秽之品。
4．舌绛，望之若干，扪之有津者
乃津液不足，湿热熏蒸，痰浊将要蒙蔽心包。急宜化痰泄浊，清心开窍。
5．舌绛而中心干燥者
系心胃火燔，劫灼津液也。治宜清营救液。
6．舌绛而光亮如镜者
系心营被灼，胃阴亦亡也。治宜急用甘凉濡润之品大剂频服，色转红活者可救，板滞者多不救。(红活、板滞系津液复与否的表现。)
7．舌绛苔少，兼脉虚气弱欲脱者
系温邪深入下焦，劫灼真阴，邪少虚多之证。治宜急用大剂咸寒救阴。兼手蠕动者，宜加潜阳之品以镇摄内风。
8．舌绛不鲜，舌质干枯而萎者
系肾阴将竭之危证。治宜急滋阴液，缓则肾阴涸极，无法挽救。
9．初起舌红绛无苔，经清营透泄治疗后，红绛渐退，苔垢渐生者
乃伏气温病，由营分血分转出气分也。
(三)紫舌
紫较绛色更深，舌由绛变紫，系热势更盛之表现，但淡紫、青紫多是寒证。
1．舌紫而干燥
系热结下焦，劫灼肝肾之阴，这是一种坏证，虽兼大便秘结、齿黑、唇焦等里热证，不可攻下。治宜滋水养阴，佐以清热。
2．舌焦紫起刺，形如杨梅
为热邪深入血分，甚则引起痉厥之证。治宜清热凉血，兼痉厥者兼用熄风之药。伴有大便秘结者，乃大热大毒之证，治宜清热解毒，方用更衣丸，加金汁、人中黄之类大清大解。
3．舌紫而干枯，或如猪肝晦暗无津者
都是肾液已竭难治之症。
4．舌淡紫而带青滑，兼恶寒肢冷、脉微者
阳虚有寒也。治宜温运。
5．舌紫而瘀暗，扪之润泽，或兼胸胁腹部刺痛者
乃胸膈素有瘀血，遇热传营血，二证互结之证。治宜清热散瘀，否则易导致如狂之变证。 二、舌苔 (一)舌无苔 多系表证。脉诀云：舌上无苔为在表。但必须兼有表证症状，否则为正常现象。
舌无苔而舌质异常也是病象。
(二)白苔
1．白苔在诊疗方面应注意苔之厚薄和燥润，以及其他_些情况。
(1)薄厚：薄者病在表而势轻，厚者邪多偏里而势重。
(2)润燥：润泽者系津液尚足，干燥者系津液已伤。
(3)湿痰、秽浊：粘腻者多夹湿痰，腐垢者多兼秽浊。
(4)可下、不可下：白苔一般不可下，但白砂苔非下不可。
(5)轻重：白苔病情一般轻浅，但白霉苔病情十分险恶。
2．根据白苔的具体表现不同，又可分为以下几类：
(1)舌苔薄白而润，舌质正常者
兼恶寒重，发热轻，口中和，小便清白等，为外感风寒的太阳病。治宜辛温解表的方法。
(2)舌苔薄白而滑者
兼头身疼重，寒热无汗，胸闷者，为湿温初起。治宜“雷氏芳香化浊法”。
(3)舌苔薄白欠润，舌边或舌尖色红者
兼开始微恶风寒，继则但发热不恶寒，口干，小便黄，为新感温病或新邪引动伏邪的春温病。治宜辛凉透解、辛凉解表等方法。
(4)舌苔薄白而干，舌边或舌尖色红者
为表未解而肺滓已伤的证候。治宜凉散之中佐以甘凉生津之品。凉散即辛凉解表之法，甘凉生津之品常用生石膏、花粉、玉竹、麦冬、知母之类。注意此时生津之品不宜过用，恐柔润滞邪。
(5)舌苔白厚而粘腻者
或兼吐浊厚涎沫，为温邪夹湿之证。治宜芳香辛散之品．如藿香正气散之类。
(6)舌苔白厚而干燥者
为胃燥气伤之证。治宜滋润药中加甘草。滋润药用生石膏、麦冬、元参、生地、知母之类，甘草取甘守津还之意。
(7)舌苔白腻而质绛者
有两种现象：一系湿遏热伏之证，治宜先辛开苦降以泄湿透热(系化湿法中的一种方法，适用于湿渐化热或湿遏热伏之证，如小陷胸汤)，次用苦辛甘凉，从里透外，使胃气化而津输布，舌虽干燥(这是湿化以后的现象，与标题上的腻并不矛盾)，也易转润而热随汗解。二系营分有热兼夹痰浊，脉滑胸闷，须防浊痰蒙闭，形成神志昏迷之证。
(8)舌苔白如碱状者
系胃中有宿滞，夹秽浊郁伏之证。治宜急行开泄，以防闭结中湿，不能外达。
(9)舌苔自如粉而滑，舌质四边紫绛者
系秽浊壅盛，热邪被其郁闭，不得透达于外，时疫邪入膜原，未归胃腑，多有此苔。治宜急速透解，以防传陷。
(10)舌苔由白变黄燥或变黑色者
白而兼黄者，为人气分之征象；变黄燥者，系邪已入胃腑，宜加大黄；变黑色者，病势更甚，宜承气攻下；一日三变者，其热更剧，更宜急下。
(11)舌苔白干硬如砂皮者
名为白砂舌，由于燥热过甚，津液被灼所致。治宜急行攻下，并佐以甘凉救液之品，最忌表散。(白苔主表，一般不可攻下，但此苔非急于攻下不可，这是应该注意的。)
(12)满舌生白衣如霉，或生白点如细碎饭粒，甚者弥漫满舌及唇腭者，叫白霉舌。多见于湿毒、湿温、伏暑等证，多系胃气败的征象，预后多不良。治宜急用甘淡养胃，待胃气渐复或可挽救，如口气秽恶，汤水难咽，或糜点拭去旋生，病多危险。
(二)黄苔
1．舌苔黄而兼白者
为邪在气分而卫分之邪犹未尽也，或系湿遏热伏。治宜辛凉开泄，宣透气分。不可轻投二黄苦泄之品，以免引邪入里。
2．舌苔黄而燥者
为邪已入阳明之里，热炽津伤，必大渴引饮。治宜辛凉清热，方用白虎汤之类。
3．舌苔黄厚坚敛或燥起刺，或中有裂纹者
症兼腹胀，硬痛拒按，大便秘者，系阳明热燥实之证。治宜攻下之法，以泄热救阴。方用承气汤之类，如增液承气汤。
4．舌苔黄而腻，或黄而浊，光滑不燥者
系无形之湿热熏蒸，虽兼脘痛痞胀，慎不可乱投苦泄攻下，宜从开泄为治，轻则用杏、蔻、橘等轻苦微辛之品，以宣通气滞，重则用枳实、黄连、半夏等。 5．黄苔兼黑者 为大热伤津也。 (四)黑苔 舌苔黑有寒热虚实之别，但温病实热证多，虚寒证少。 1．黑苔枯燥裂起刺，舌质干涩苍老者 是大热大毒之证，如腹硬痛拒按，脉沉数有力者，为津伤液燥，阳明腑实，治宜急下存阴，或与增液养阴之剂同用；如热邪尚未结实，腹不拒按者，宜用大剂清热之剂治之。 2．黑苔焦黑干枯者 脉虚数或细数，胸腹不胀满拒按者，系温邪日久不愈，深入下焦，津枯液竭，真阴衰微，水不制火之证。治宜急用大剂咸寒利水之剂，缓则液涸不救。此证绝对禁忌攻下!
3．黑苔，其黑色不浓或黑中灰滑而润，舌质也不红赤者
兼脉微肢冷，便溏不渴等症者，乃虚寒证也。治宜温经回阳，佐以补气血之剂。王孟英云：“凡虚寒证，虽见黑苔，其舌必润而紫赤。”
4．温病初起遍舌色黑而润者
兼发热胸闷，渴喜热饮，此外无其他险恶症状者，乃胸膈素有伏痰，不必张皇。治宜凉散中佐以辛温或辛滑开泄之品。伏痰一化，黑苔自退。
5．温病后期，邪入血分，大量出血，舌质淡白无华，舌苔发黑者
乃阴伤气脱之证，其脉必微弱或虚数。治宜独参汤以益气固脱，绝不可拘泥于苔黑而恣意寒凉。
6．苔由黄转黑或黑而燥刺者
系温病大热伤津之证。
(五)灰苔
舌灰苔系由白苔或黄苔转黑的过程中出现的一种舌苔，在病势程度上较黑苔稍轻，诊断方法与黑苔大体相同。
1．灰苔而润或灰腻、灰黄者
如始病即见为湿温夹食或夹停饮之证，当随兼证决定治法。
2．灰而白腻，舌色红者
兼胸闷烦渴，为伏暑或湿温，湿热交阻，热处湿中之证。治宜苦辛淡渗，行气化湿。
3．灰苔清滑者
兼四肢逆冷，下利者，乃少阴虚寒之证。治宜温阳祛寒，方用理中、四逆等。
湿温病的发热特点及其证治
湿温病多发于长夏初秋，大暑至白露的季节，因为该时天气炎热，雨水较多，人在这样湿热交蒸的气候中，如果中阳素虚，或恣食肥甘生冷，或劳倦饥饱过度，使脾胃受伤，最易发生本病。
发热是湿温病的常见症状之一，与其他疾病相比，湿温病的发热又具有自己独特的特点，掌握这些特征，对辨证用药很有好处。兹详述于下：
1．发热兼恶风寒
始恶寒，后但热不寒：始恶寒者阳为湿郁而恶寒，非若寒伤于表之恶寒，后但热不寒则郁久成热。反恶热矣。
恶寒，身重头痛，有汗或无汗：为湿在表分，卫阳被遏之证也。宜羌活、葛根、苍术等药治之，头不痛者去羌活。
2．午后身热或午后热重
此证与疟疾不同的关键是湿温的热没有退清的时候，疟疾的热不限于午后，且有退清的时候。
此证与阴虚不同的关键是阴虚有咳嗽痰血的病史，且是慢性病；湿温病没有那些病史，而且是季节性的急性病。
3．高热突然降至常温以下
兼汗出、肢冷、脉细者每有虚脱之变，这是恶候症状之一。
4．乍寒乍热如疟
这是卫分气分兼见之症。
以上是湿温病发生发展过程中可能见到的发热类型及其特点。对于湿温初起的发热，其治疗也不同于一般温病及伤寒之治。
湿温初起，邪在卫分，症见发热、恶寒、头痛、身重、体痛等，兼胸满舌腻者，为表阳被湿邪所遏之证，治宜芳香宣化，开痰理湿(即开肺气、化脾湿)。若单纯疏散解表，不兼开泄宽胸之药，则热必不除或更加炽甚。因为这是湿热互相郁结之证，与风寒在表之热完全不同，单纯疏散，不但扰动在内之湿痰，使之益形猖獗，也易损伤津液，致热势更甚。
温热之邪，初入肺卫（肺与卫分），治以银翘散时，不可因初起病轻而忽略兼夹。必须详审病情，随症适当加减，方能见效。如初起恶寒，可将芦根易葱白，或将芥穗适当增量，再辅以防风，酌情采用。如无恶寒，芥穗即可不用。咳者，牛蒡子、桔梗适当增量。热甚者，又当辨其性质，如燥热甚加石膏、知母；湿热有火则加黄芩之类。温病初起，治宜清凉辛散，最易忽略兼夹恶寒，须要配以温散的一面。只有细察之，并随症加减，庶几面面周到，用药必然有效，否则虽不致一下坏事，但亦能迁延病机，损耗津液，成为以后变证的因素。这是需要引起高度注意的。
温病重在辨舌
温病化燥伤阴最速，表现在舌的方面最为显著，通过舌诊可以辨别受邪的浅深，疾病的轻重，津液的存亡，所以李老在诊治温病时非常注重辨舌。他认为舌的症状主要表现在舌苔、舌质及舌的感觉等方面，而且辨舌应该结合患者的兼见症状，综合分析辨证，进而提出治法及方剂。
现将李老对舌诊的论述总结于下：
一、舌质
(一)红舌
凡见红舌，均系热证，凡温热病初起，舌质深红者都是伏气温病，因为郁热在里的缘故。
1．舌尖红赤起刺，系心火上炎，治宜清凉泻火。
2．舌红中有裂纹如人字形者，系心火内燔，热毒熏蒸。
3．舌红中有红点者系热毒更盛。
以上二证均可于清凉泻火中加入解毒药品。
4．舌质光红柔嫩，望之似觉潮润，扪之干燥无津者名镜面舌，系津液枯竭的现象，温病后期多见此舌。
5．舌淡红无色，干而不荣者，系心脾气血虚弱，胃津已伤，气不化液之证，用药不可过于寒凉，可仿炙甘草汤法治之。
6．舌四边色红，中心干燥，兼黄白苔者，系上焦气分无形之邪热灼伤津液，切忌早用咸寒滋腻血分的药品，以免邪不外解，有误病机。
7．红舌兼黄白苔者，系上焦气分之邪未尽，不可早用滋腻血分之药。
(二)绛舌
绛，系红色之深者，舌色由红而绛，乃热邪深入，由营分入血分的主要表现，以苔之有无，色之深浅、鲜晦，质之燥润、荣枯为辨证的准则。但必须结合其他营分血分的症状方能准确辨证。
1．舌绛而不干燥，兼有黄白苔者
系邪入营分血分，而气分之邪未尽，滓液未伤。治宜宣气透营，使邪仍由气分而解，不可单纯用凉血药，因血药滋腻，易致邪气遏伏，不能外透。
2．舌纯绛无苔，色鲜泽者
乃舌苔尽化，邪已人营血。治宜清营凉血。若邪入心包络则神昏内闭，治宜清心开窍，轻者用菖蒲、郁金开之，重者用牛黄丸、至宝丹、紫雪丹芳香开窍；若兼火痰，必致痰火内闭，更当加西黄、川贝、竹沥、竺黄之类清火豁痰。
3．舌绛，兼有粘腻，似苔非苔现象者
乃营分有热，夹秽浊之气也。治宜清泄营热，兼用芳香逐秽之品。
4．舌绛，望之若干，扪之有津者
乃津液不足，湿热熏蒸，痰浊将要蒙蔽心包。急宜化痰泄浊，清心开窍。
5．舌绛而中心干燥者
系心胃火燔，劫灼津液也。治宜清营救液。
6．舌绛而光亮如镜者
系心营被灼，胃阴亦亡也。治宜急用甘凉濡润之品大剂频服，色转红活者可救，板滞者多不救。(红活、板滞系津液复与否的表现。)
7．舌绛苔少，兼脉虚气弱欲脱者
系温邪深入下焦，劫灼真阴，邪少虚多之证。治宜急用大剂咸寒救阴。兼手蠕动者，宜加潜阳之品以镇摄内风。
8．舌绛不鲜，舌质干枯而萎者
系肾阴将竭之危证。治宜急滋阴液，缓则肾阴涸极，无法挽救。
9．初起舌红绛无苔，经清营透泄治疗后，红绛渐退，苔垢渐生者
乃伏气温病，由营分血分转出气分也。
(三)紫舌
紫较绛色更深，舌由绛变紫，系热势更盛之表现，但淡紫、青紫多是寒证。
1．舌紫而干燥
系热结下焦，劫灼肝肾之阴，这是一种坏证，虽兼大便秘结、齿黑、唇焦等里热证，不可攻下。治宜滋水养阴，佐以清热。
2．舌焦紫起刺，形如杨梅
为热邪深入血分，甚则引起痉厥之证。治宜清热凉血，兼痉厥者兼用熄风之药。伴有大便秘结者，乃大热大毒之证，治宜清热解毒，方用更衣丸，加金汁、人中黄之类大清大解。
3．舌紫而干枯，或如猪肝晦暗无津者
都是肾液已竭难治之症。
4．舌淡紫而带青滑，兼恶寒肢冷、脉微者
阳虚有寒也。治宜温运。
5．舌紫而瘀暗，扪之润泽，或兼胸胁腹部刺痛者
乃胸膈素有瘀血，遇热传营血，二证互结之证。治宜清热散瘀，否则易导致如狂之变证。 二、舌苔 (一)舌无苔 多系表证。脉诀云：舌上无苔为在表。但必须兼有表证症状，否则为正常现象。
舌无苔而舌质异常也是病象。
(二)白苔
1．白苔在诊疗方面应注意苔之厚薄和燥润，以及其他_些情况。
(1)薄厚：薄者病在表而势轻，厚者邪多偏里而势重。
(2)润燥：润泽者系津液尚足，干燥者系津液已伤。
(3)湿痰、秽浊：粘腻者多夹湿痰，腐垢者多兼秽浊。
(4)可下、不可下：白苔一般不可下，但白砂苔非下不可。
(5)轻重：白苔病情一般轻浅，但白霉苔病情十分险恶。
2．根据白苔的具体表现不同，又可分为以下几类：
(1)舌苔薄白而润，舌质正常者
兼恶寒重，发热轻，口中和，小便清白等，为外感风寒的太阳病。治宜辛温解表的方法。
(2)舌苔薄白而滑者
兼头身疼重，寒热无汗，胸闷者，为湿温初起。治宜“雷氏芳香化浊法”。
(3)舌苔薄白欠润，舌边或舌尖色红者
兼开始微恶风寒，继则但发热不恶寒，口干，小便黄，为新感温病或新邪引动伏邪的春温病。治宜辛凉透解、辛凉解表等方法。
(4)舌苔薄白而干，舌边或舌尖色红者
为表未解而肺滓已伤的证候。治宜凉散之中佐以甘凉生津之品。凉散即辛凉解表之法，甘凉生津之品常用生石膏、花粉、玉竹、麦冬、知母之类。注意此时生津之品不宜过用，恐柔润滞邪。
(5)舌苔白厚而粘腻者
或兼吐浊厚涎沫，为温邪夹湿之证。治宜芳香辛散之品．如藿香正气散之类。
(6)舌苔白厚而干燥者
为胃燥气伤之证。治宜滋润药中加甘草。滋润药用生石膏、麦冬、元参、生地、知母之类，甘草取甘守津还之意。
(7)舌苔白腻而质绛者
有两种现象：一系湿遏热伏之证，治宜先辛开苦降以泄湿透热(系化湿法中的一种方法，适用于湿渐化热或湿遏热伏之证，如小陷胸汤)，次用苦辛甘凉，从里透外，使胃气化而津输布，舌虽干燥(这是湿化以后的现象，与标题上的腻并不矛盾)，也易转润而热随汗解。二系营分有热兼夹痰浊，脉滑胸闷，须防浊痰蒙闭，形成神志昏迷之证。
(8)舌苔白如碱状者
系胃中有宿滞，夹秽浊郁伏之证。治宜急行开泄，以防闭结中湿，不能外达。
(9)舌苔自如粉而滑，舌质四边紫绛者
系秽浊壅盛，热邪被其郁闭，不得透达于外，时疫邪入膜原，未归胃腑，多有此苔。治宜急速透解，以防传陷。
(10)舌苔由白变黄燥或变黑色者
白而兼黄者，为人气分之征象；变黄燥者，系邪已入胃腑，宜加大黄；变黑色者，病势更甚，宜承气攻下；一日三变者，其热更剧，更宜急下。
(11)舌苔白干硬如砂皮者
名为白砂舌，由于燥热过甚，津液被灼所致。治宜急行攻下，并佐以甘凉救液之品，最忌表散。(白苔主表，一般不可攻下，但此苔非急于攻下不可，这是应该注意的。)
(12)满舌生白衣如霉，或生白点如细碎饭粒，甚者弥漫满舌及唇腭者，叫白霉舌。多见于湿毒、湿温、伏暑等证，多系胃气败的征象，预后多不良。治宜急用甘淡养胃，待胃气渐复或可挽救，如口气秽恶，汤水难咽，或糜点拭去旋生，病多危险。
(二)黄苔
1．舌苔黄而兼白者
为邪在气分而卫分之邪犹未尽也，或系湿遏热伏。治宜辛凉开泄，宣透气分。不可轻投二黄苦泄之品，以免引邪入里。
2．舌苔黄而燥者
为邪已入阳明之里，热炽津伤，必大渴引饮。治宜辛凉清热，方用白虎汤之类。
3．舌苔黄厚坚敛或燥起刺，或中有裂纹者
症兼腹胀，硬痛拒按，大便秘者，系阳明热燥实之证。治宜攻下之法，以泄热救阴。方用承气汤之类，如增液承气汤。
4．舌苔黄而腻，或黄而浊，光滑不燥者
系无形之湿热熏蒸，虽兼脘痛痞胀，慎不可乱投苦泄攻下，宜从开泄为治，轻则用杏、蔻、橘等轻苦微辛之品，以宣通气滞，重则用枳实、黄连、半夏等。 5．黄苔兼黑者 为大热伤津也。 (四)黑苔 舌苔黑有寒热虚实之别，但温病实热证多，虚寒证少。 1．黑苔枯燥裂起刺，舌质干涩苍老者 是大热大毒之证，如腹硬痛拒按，脉沉数有力者，为津伤液燥，阳明腑实，治宜急下存阴，或与增液养阴之剂同用；如热邪尚未结实，腹不拒按者，宜用大剂清热之剂治之。 2．黑苔焦黑干枯者 脉虚数或细数，胸腹不胀满拒按者，系温邪日久不愈，深入下焦，津枯液竭，真阴衰微，水不制火之证。治宜急用大剂咸寒利水之剂，缓则液涸不救。此证绝对禁忌攻下!
3．黑苔，其黑色不浓或黑中灰滑而润，舌质也不红赤者
兼脉微肢冷，便溏不渴等症者，乃虚寒证也。治宜温经回阳，佐以补气血之剂。王孟英云：“凡虚寒证，虽见黑苔，其舌必润而紫赤。”
4．温病初起遍舌色黑而润者
兼发热胸闷，渴喜热饮，此外无其他险恶症状者，乃胸膈素有伏痰，不必张皇。治宜凉散中佐以辛温或辛滑开泄之品。伏痰一化，黑苔自退。
5．温病后期，邪入血分，大量出血，舌质淡白无华，舌苔发黑者
乃阴伤气脱之证，其脉必微弱或虚数。治宜独参汤以益气固脱，绝不可拘泥于苔黑而恣意寒凉。
6．苔由黄转黑或黑而燥刺者
系温病大热伤津之证。
(五)灰苔
舌灰苔系由白苔或黄苔转黑的过程中出现的一种舌苔，在病势程度上较黑苔稍轻，诊断方法与黑苔大体相同。
1．灰苔而润或灰腻、灰黄者
如始病即见为湿温夹食或夹停饮之证，当随兼证决定治法。
2．灰而白腻，舌色红者
兼胸闷烦渴，为伏暑或湿温，湿热交阻，热处湿中之证。治宜苦辛淡渗，行气化湿。
3．灰苔清滑者
兼四肢逆冷，下利者，乃少阴虚寒之证。治宜温阳祛寒，方用理中、四逆等。
湿温病的发热特点及其证治
湿温病多发于长夏初秋，大暑至白露的季节，因为该时天气炎热，雨水较多，人在这样湿热交蒸的气候中，如果中阳素虚，或恣食肥甘生冷，或劳倦饥饱过度，使脾胃受伤，最易发生本病。
发热是湿温病的常见症状之一，与其他疾病相比，湿温病的发热又具有自己独特的特点，掌握这些特征，对辨证用药很有好处。兹详述于下：
1．发热兼恶风寒
始恶寒，后但热不寒：始恶寒者阳为湿郁而恶寒，非若寒伤于表之恶寒，后但热不寒则郁久成热。反恶热矣。
恶寒，身重头痛，有汗或无汗：为湿在表分，卫阳被遏之证也。宜羌活、葛根、苍术等药治之，头不痛者去羌活。
2．午后身热或午后热重
此证与疟疾不同的关键是湿温的热没有退清的时候，疟疾的热不限于午后，且有退清的时候。
此证与阴虚不同的关键是阴虚有咳嗽痰血的病史，且是慢性病；湿温病没有那些病史，而且是季节性的急性病。
3．高热突然降至常温以下
兼汗出、肢冷、脉细者每有虚脱之变，这是恶候症状之一。
4．乍寒乍热如疟
这是卫分气分兼见之症。
以上是湿温病发生发展过程中可能见到的发热类型及其特点。对于湿温初起的发热，其治疗也不同于一般温病及伤寒之治。
湿温初起，邪在卫分，症见发热、恶寒、头痛、身重、体痛等，兼胸满舌腻者，为表阳被湿邪所遏之证，治宜芳香宣化，开痰理湿(即开肺气、化脾湿)。若单纯疏散解表，不兼开泄宽胸之药，则热必不除或更加炽甚。因为这是湿热互相郁结之证，与风寒在表之热完全不同，单纯疏散，不但扰动在内之湿痰，使之益形猖獗，也易损伤津液，致热势更甚。
When pathogenic heat-warmth factors initially invade the Lung and Wei (Defensive) levels, and Yin Qiao San (Honeysuckle and Forsythia Decoction) is indicated, one must not ignore concurrent complications merely because the initial illness is mild. It is essential to carefully examine the condition and make appropriate modifications to the prescription based on symptoms to achieve efficacy. If chills are present at the onset, Lu Gen (Reed Rhizome) may be replaced with Cong Bai (Scallion White), or Jie Sui (Schizonepeta Head) may be appropriately increased in dosage, supplemented by Fang Feng (Saposhnikovia Root) as appropriate. If there are no chills, Jie Sui need not be used. For coughing, Niu Bang Zi (Arctium Fruit) and Jie Geng (Platycodon Root) should be appropriately increased. In cases of severe heat, its nature must be differentiated: if dry-heat is severe, add Shi Gao (Gypsum) and Zhi Mu (Anemarrhena Rhizome); if damp-heat with fire is present, add Huang Qin (Scutellaria Root). The treatment for early-stage warm diseases should employ cooling and acrid-dispersing methods. It is easiest to overlook concurrent chills; therefore, warming-dispersing agents must be paired. Only through meticulous observation and symptom-based modifications can the treatment be comprehensive and effective. Otherwise, although it may not cause immediate deterioration, it can prolong the disease process, consume body fluids, and become a factor for subsequent transformation of the disease. This requires high attention.
Warm diseases emphasize tongue diagnosis.
The transformation into dryness and injury to Yin occurs most rapidly in warm diseases, which is most significantly manifested in the tongue. Through tongue diagnosis, one can distinguish the depth of pathogen invasion, the severity of the disease, and the preservation or depletion of body fluids. Therefore, Master Li places great emphasis on tongue diagnosis when treating warm diseases. He believes that tongue symptoms mainly manifest in the tongue coating, tongue body, and tongue sensation. Tongue diagnosis should be combined with the patient's accompanying symptoms for comprehensive analysis and differentiation, thereby proposing treatment methods and prescriptions.
Master Li's discussions on tongue diagnosis are summarized below:
I. Tongue Body
(A) Red Tongue
A red tongue always indicates a heat syndrome. In the early stage of warm-heat diseases, a deep red tongue body indicates latent heat-warmth disease due to constrained heat within.
1. A red tip with prickles indicates Heart Fire flaming upward; treatment should employ cooling and purging fire methods.
2. A red tongue with human-shaped cracks indicates internal blazing of Heart Fire and steaming by heat-toxins.
3. A red tongue with red spots indicates even more intense heat-toxins.
For the above two conditions, detoxifying herbs can be added to cooling and purging fire formulas.
4. A tongue body that is smooth, red, tender, appearing moist to the eye but dry and fluidless upon touch is called a "Mirror Tongue." This indicates exhaustion of body fluids and is common in the late stages of warm diseases.
5. A pale-red, colorless tongue that is dry and lacks luster indicates deficiency of Qi and Blood of the Heart and Spleen, injury to Stomach fluids, and failure of Qi to transform fluids. Medications should not be overly cold; one may imitate the method of Zhi Gan Cao Tang (Honey-fried Licorice Decoction).
6. A tongue with red edges and center, accompanied by yellow-white coating, indicates invisible pathogenic heat in the Upper Jiao Qi level scorching body fluids. One must strictly avoid using salty-cold, cloying blood-level medications early on to prevent pathogens from being trapped inside and misdirecting the disease process.
7. A red tongue with yellow-white coating indicates that pathogens in the Upper Jiao Qi level have not yet cleared; cloying blood-level medications should not be used early.
(B) Crimson Tongue
Crimson is a deeper shade of red. The transition of tongue color from red to crimson is the main manifestation of pathogenic heat penetrating deeply from the Ying (Nutritive) level to the Xue (Blood) level. The presence or absence of coating, the depth and brightness of color, and the dryness or moisture/luster of the body serve as criteria for differentiation. However, accurate differentiation must combine other Ying and Xue level symptoms.
1. A crimson tongue that is not dry, accompanied by yellow-white coating
Indicates pathogens entering Ying and Xue levels while Qi level pathogens remain incomplete, and body fluids are not yet injured. Treatment should promote Qi circulation to vent Ying level pathogens, allowing them to resolve via the Qi level. Pure blood-cooling medications should not be used solely, as blood-level herbs are cloying and may trap pathogens, preventing external release.
2. A pure crimson tongue without coating, bright and lustrous
Indicates complete loss of coating and pathogens having entered Ying and Blood levels. Treatment should clear Ying and cool Blood. If pathogens enter the Pericardium causing unconsciousness and internal closure, treatment should clear the Heart and open orifices. For mild cases, use Chang Pu (Acorus Rhizome) and Yu Jin (Curcuma Root); for severe cases, use Niu Huang Wan (Calculus Bovis Pill), Zhi Bao Dan (Precious Treasure Pill), or Zi Xue Dan (Purple Snow Pill) to open orifices with aromatic properties. If accompanied by fire-phlegm leading to phlegm-fire internal closure, add Xi Huang (Musk), Chuan Bei Mu (Fritillaria Bulb), Zhu Li (Bamboo Sap), and Zhu Ru (Bamboo Shavings) to clear fire and resolve phlegm.
3. A crimson tongue with sticky texture, resembling a coating but not quite
Indicates heat in the Ying level mixed with turbid miasma. Treatment should clear and drain Ying heat, combined with aromatic herbs to dispel turbidity.
4. A crimson tongue that appears dry but feels moist to the touch
Indicates insufficient body fluids, steaming by damp-heat, and impending clouding of the Pericardium by turbid phlegm. Urgent treatment should resolve phlegm and drain turbidity, clearing the Heart and opening orifices.
5. A crimson tongue with a dry center
Indicates blazing Fire of the Heart and Stomach consuming body fluids. Treatment should clear Ying and nourish fluids.
6. A crimson tongue bright and mirror-like
Indicates scorching of Heart Ying and exhaustion of Stomach Yin. Urgent treatment should administer large doses of sweet-cool moistening substances frequently. If the color turns vibrant red, it can be saved; if stiff and stagnant, it is mostly incurable. (Vibrancy vs. stagnation reflects the return or lack thereof of body fluids.)
7. A crimson tongue with little coating, accompanied by deficient pulse and weak Qi nearing collapse
Indicates warm pathogens penetrating deeply into the Lower Jiao, consuming True Yin, a condition where pathogens are few and deficiency is predominant. Urgent treatment should employ large doses of salty-cold Yin-nourishing agents. If accompanied by hand twitching, add Yang-subduing agents to calm internal wind.
8. A crimson tongue lacking freshness, with dry, shriveled body
Indicates a critical condition of impending Kidney Yin exhaustion. Urgent treatment should nourish Yin fluids; otherwise, once Kidney Yin is completely depleted, it cannot be saved.
9. Early stage crimson tongue without coating, after Ying-clearing and venting treatment, crimson fades and coating gradually grows
Indicates latent heat-warmth disease transferring from Ying and Blood levels back to the Qi level.
(C) Purple Tongue
Purple is darker than crimson. Transition from crimson to purple indicates more intense heat. However, pale purple or bluish-purple often indicates cold syndromes.
1. A purple and dry tongue
Indicates heat binding in the Lower Jiao, consuming Liver and Kidney Yin. This is a deteriorated condition. Even if accompanied by interior heat signs like constipation, black teeth, and scorched lips, purgation should not be used. Treatment should nourish Water and Yin, assisted by clearing heat.
2. A scorched purple tongue with prickles, shaped like a bayberry
Indicates heat pathogens deeply entering Blood levels, potentially causing spasms and convulsions. Treatment should clear heat and cool blood; for spasms/convulsions, add wind-extinguishing herbs. With constipation, indicating extreme heat and toxicity, treatment should clear heat and resolve toxins using Geng Yi Wan (Clothing Change Pill), adding Jin Zhi (Gold Juice) and Ren Zhong Huang (Human Middle Yellow) for strong purification.
3. A purple, dry, shriveled tongue, or dark like a pig liver without fluids
Indicates exhaustion of Kidney fluids, a difficult-to-treat condition.
4. A pale purple tongue with bluish slipperiness, accompanied by chills, cold limbs, and faint pulse
Indicates Yang deficiency with cold. Treatment should warm and move.
5. A purple, dark,瘀 (stagnant) tongue, moist to touch, or accompanied by stabbing pain in chest/hypochondrium/abdomen
Indicates pre-existing blood stasis in the chest/diaphragm, combining with heat transmitted to Ying/Blood levels. Treatment should clear heat and dissipate stasis; otherwise, it may lead to manic-like transformations.
II. Tongue Coating
(A) Absence of Coating
Mostly indicates exterior syndromes. Pulse classics state: "No coating on tongue means pathogen is in the exterior." However, this must be accompanied by exterior symptoms; otherwise, it is normal. Abnormal tongue body without coating is also a pathological sign.
(B) White Coating
1. Attention should be paid to thickness and moisture/dryness of white coating, and other situations.
(1) Thickness: Thin indicates exterior disease with mild progression; thick indicates pathogen leaning inward with severe progression.
(2) Moisture/Dryness: Moist indicates sufficient fluids; dry indicates injured fluids.
(3) Damp-phlegm/Turbidity: Sticky indicates damp-phlegm; foul/grimy indicates turbidity.
(4) Purgation applicable/not applicable: White coating generally does not require purgation, but White Sand Coating requires purgation.
(5) Severity: White coating usually indicates mild/shallow disease, but White Mold Coating indicates extremely dangerous condition.
2. Based on specific manifestations, white coating can be classified as follows:
(1) Thin, white, moist coating with normal tongue body
Accompanied by heavy chills, mild fever, neutral mouth taste, clear urine, etc., indicates Taiyang disease from Wind-Cold exterior contraction. Treatment should employ acrid-warm exterior-releasing methods.
(2) Thin, white, slippery coating
Accompanied by heavy head/body pain, alternating chills/fever without sweat, chest stuffiness, indicates early-stage Damp-Warmth. Treatment should use "Lei's Aromatic Turbidity-Resolving Method."
(3) Thin, white, slightly dry coating with red edges or tip
Accompanied by initial mild aversion to wind/cold, followed by fever without chills, dry mouth, yellow urine, indicates newly acquired warm disease or Spring Warmth triggered by new pathogens acting on latent pathogens. Treatment should employ acrid-cool venting/resolving or acrid-cool exterior-releasing methods.
(4) Thin, white, dry coating with red edges or tip
Indicates unresolved exterior with injured Lung fluids. Treatment should add sweet-cool fluid-generating products to cooling-dispersing methods. Cooling-dispersing refers to acrid-cool exterior-releasing; sweet-cool fluid generators commonly include raw Shi Gao (Gypsum), Hua Fen (Trichosanthes Root), Yu Zhu (Polygonatum Odoratum Rhizome), Mai Dong (Ophiopogon Tuber), and Zhi Mu (Anemarrhena Rhizome). Note: Fluid generators should not be overused here to avoid softening/stagnating pathogens.
(5) Thick, white, sticky coating
Or accompanied by vomiting thick turbid saliva, indicates warm pathogens mixed with dampness. Treatment should use aromatic acrid-dispersing products like Huo Xiang Zheng Qi San (Agaricus and Magnolia Bark Powder).
(6) Thick, white, dry coating
Indicates Stomach dryness and Qi injury. Treatment should add Gan Cao (Licorice Root) to moistening medicines. Moistening medicines include raw Shi Gao, Mai Dong, Yuan Shen (Scrophularia Root), Sheng Di Huang (Rehmannia Root), and Zhi Mu. Licorice is used for its sweet-retaining property to restore fluids.
(7) White greasy coating with crimson tongue body
Two phenomena: First, dampness suppressing latent heat. Treatment should first use acrid-opening/bitter-draining to drain dampness and vent heat (a damp-resolving method suitable for damp transforming to heat or damp suppressing heat, e.g., Xiao Xian Xiong Tang), then use bitter-acrid-sweet-cool to vent outward from inside, promoting Stomach Qi transformation and fluid distribution. Although the tongue becomes dry (after damp resolves, contradicting 'greasy' superficially), it easily becomes moist and heat resolves with sweat. Second, Ying level heat mixed with turbid phlegm, slippery pulse, chest stuffiness; must guard against turbid phlegm clouding causing coma.
(8) White coating like alkali powder
Indicates food retention in Stomach mixed with suppressed turbidity. Treatment should urgently open and drain to prevent middle-jiao dampness closure and inability to reach exterior.
(9) White powdery slippery coating with purple-crimson edges
Indicates overwhelming turbidity, heat pathogens suppressed and unable to vent outward. Common in epidemic pathogens entering Mo Yuan (Membrane Source) before reaching Stomach Fu organs. Treatment should urgently vent and resolve to prevent transmission and sinking.
(10) White coating turning yellow-dry or black
White with yellow indicates Qi level manifestation; turning yellow-dry indicates pathogens entering Stomach Fu, should add Da Huang (Rhubarb); turning black indicates more severe condition, should use Cheng Qi (Order the Qi) purgation; changing three times in one day indicates more intense heat, requiring urgent purgation.
(11) White, dry, hard coating like sandpaper
Named White Sand Tongue, caused by excessive dry-heat scorching fluids. Treatment should urgently purge, assisted by sweet-cool fluid-saving agents. Exterior dispersal is strictly contraindicated. (White coating governs exterior, generally not purged, but this coating requires urgent purgation, which should be noted.)
(12) Full tongue covered with white mold-like substance or fine rice-grain-like white spots, spreading to lips/palate, called White Mold Tongue. Common in Damp-Toxin, Damp-Warmth, Latent Summerheat. Indicates failure of Stomach Qi, poor prognosis. Treatment should urgently use sweet-bland Stomach-nourishing agents; if Stomach Qi recovers, it may be saved. If breath is foul, difficulty swallowing soup/water, or fungal spots regenerate immediately after wiping, the disease is dangerous.
(C) Yellow Coating
1. Yellow coating with white
Indicates pathogen in Qi level while Wei level pathogens remain, or damp suppressing heat. Treatment should use acrid-cool opening/draining to vent Qi level. Do not lightly administer bitter-draining Er Huang (likely referring to specific bitter herbs) to avoid drawing pathogens inward.
2. Yellow and dry coating
Indicates pathogens entered Yangming interior, intense heat injuring fluids, causing extreme thirst and desire to drink. Treatment should use acrid-cool clearing heat, formulas like Bai Hu Tang (White Tiger Decoction).
3. Thick, firm, or dry/prickly yellow coating, or with cracks
Accompanied by abdominal distension, hard pain refusing pressure, constipation, indicates Yangming Heat-Dryness Excess. Treatment should use purgation to drain heat and save Yin, formulas like Cheng Qi Tang (Order the Qi Decoction), e.g., Zeng Ye Cheng Qi Tang (Increase Fluids Order the Qi Decoction).
4. Yellow greasy, or yellow turbid, smooth not dry coating
Indicates formless damp-heat steaming. Even with epigastric pain/distension, strictly avoid random bitter-draining purgation. Treatment should focus on opening/draining. Mild cases use Xing (Apricot Seed), Kou (Cardamom), Ju (Citrus Peel) light bitter/mild acrid to vent Qi stagnation; severe cases use Zhi Shi (Immature Bitter Orange), Huang Lian (Coptis Rhizome), Ban Xia (Pinellia Tuber).
5. Yellow coating with black
Indicates extreme heat injuring fluids.
(D) Black Coating
Black coating has cold/heat/excess/deficiency distinctions, but warm diseases mostly have excess-heat, rarely deficiency-cold.
1. Black, dry, cracked, prickly coating with dry, rough, aged tongue body
Indicates extreme heat and toxicity. If abdomen is hard/painful refusing pressure, pulse deep-rapid-forceful, indicates fluid injury/dryness, Yangming Fu organ excess. Treatment should urgently purge to preserve Yin, or combine with Zeng Ye (Increase Fluids) Yin-nourishing agents. If heat has not solidified, abdomen does not refuse pressure, use large dose heat-clearing agents.
2. Scorched black, dry, shriveled coating
Pulse deficient-rapid or fine-rapid, chest/abdomen not full/refusing pressure, indicates persistent warm pathogens penetrating Lower Jiao, fluid exhaustion, True Yin decline, Water failing to control Fire. Treatment should urgently use large doses of salty-cold diuretic/nourishing agents; delay leads to fluid depletion and incurability. Purgation is absolutely contraindicated!
3. Black coating not dense, or gray-black slippery/moist, tongue body not red
Accompanied by faint pulse, cold limbs, loose stools, no thirst, indicates deficiency-cold. Treatment should warm meridians and restore Yang, assisted by Qi-Blood tonics. Wang Mengying said: "In deficiency-cold, even with black coating, the tongue must be moist and purple-red."
4. Whole tongue black and moist at early stage of warm disease
Accompanied by fever, chest stuffiness, desire for hot drinks, no other dangerous symptoms, indicates latent phlegm in chest/diaphragm. No need for panic. Treatment should add acrid-warm or acrid-sliding opening/draining agents to cooling-dispersing. Once latent phlegm resolves, black coating retreats naturally.
5. Late stage warm disease, pathogens in Blood level, massive bleeding, pale lusterless tongue body, black coating
Indicates Yin injury and Qi collapse. Pulse must be faint or deficient-rapid. Treatment should use Du Shen Tang (Single Ginseng Decoction) to boost Qi and secure collapse. Do not rigidly adhere to black coating and recklessly use cold herbs.
6. Coating turning from yellow to black or black with dry prickles
Indicates extreme heat injuring fluids in warm disease.
(E) Gray Coating
Gray coating appears during the transition from white/yellow to black, slightly less severe than black coating, with similar diagnostic methods.
1. Gray moist, or gray greasy/yellow
If seen at onset, indicates Damp-Warmth mixed with food retention or retained fluids. Treatment depends on accompanying symptoms.
2. Gray-white greasy, red tongue body
Accompanied by chest stuffiness, irritability/thirst, indicates Latent Summerheat or Damp-Warmth, damp-heat interlocking, heat located within damp. Treatment should use bitter-acrid-bland draining to move Qi and resolve damp.
3. Clear/slipping gray coating
Accompanied by cold extremities, diarrhea, indicates Shaoyin deficiency-cold. Treatment should warm Yang and dispel cold, formulas like Li Zhong (Regulate the Middle) or Si Ni (Reverse the Cold).
Fever Characteristics and Treatment of Damp-Warmth Disease
Damp-Warmth disease occurs mostly in late summer/early autumn, from Great Heat to White Dew season. Due to hot weather and abundant rain, people with inherent Spleen-Yang deficiency, excessive consumption of rich/greasy/cold foods, or fatigue/starvation-induced Spleen/Stomach injury are most susceptible.
Fever is a common symptom of Damp-Warmth. Compared to other diseases, Damp-Warmth fever has unique characteristics. Mastering these aids differentiation and medication. Detailed below:
1. Fever with aversion to wind/cold
Initial chills, later only heat without chills: Initial chills are due to Yang constrained by dampness, different from exterior Cold injury chills. Later heat without chills results from long-term constraint generating heat, leading to aversion to heat.
Chills, heavy body/headache, with or without sweat: Indicates damp in exterior level, Defensive Yang suppressed. Treat with Qiang Huo (Notopterygium Root), Ge Gen (Kudzu Root), Cang Zhu (Atractylodes Rhizome), etc. Remove Qiang Huo if no headache.
2. Afternoon fever or heavier afternoon heat
Key difference from Malaria: Damp-Warmth heat never fully clears; Malaria heat is not limited to afternoon and has periods of clearance.
Key difference from Yin Deficiency: Yin Deficiency has history of cough/blood-streaked sputum and is chronic; Damp-Warmth lacks this history and is seasonal acute.
3. High fever suddenly dropping below normal
Accompanied by sweating, cold limbs, fine pulse often indicates collapse transformation, a malignant sign.
4. Alternating chills and heat like malaria
This is a simultaneous Wei and Qi level symptom.
Above are possible fever types and characteristics in Damp-Warmth development. Treatment for early Damp-Warmth fever differs from general warm diseases and Shang Han (Cold Damage).
Early Damp-Warmth, pathogens in Wei level, symptoms of fever, chills, headache, heaviness, body pain, plus chest fullness and greasy tongue, indicate exterior Yang suppressed by dampness. Treatment should use aromatic ventilation/transformation, opening phlegm and regulating damp (i.e., opening Lung Qi, resolving Spleen damp). Pure exterior dispersal without opening/draining/chest-broadening herbs will fail to remove heat or worsen it. This is because damp and heat constrain each other, completely different from exterior Wind-Cold heat. Pure dispersal disturbs internal damp-phlegm, making it rampant, and easily injures fluids, intensifying heat.