舌见四边微红。中央灰黑色者。此由失下而致。用大承气汤下之。热退可愈。必三四下方退。五次下之而不退者。
不治。
\r微红黑灰舌图\pt101a29.bmp\r
【介按】舌见灰色。病概不轻。均是里症。无表症。有实热症、无虚寒症。又有邪热传里。时疫流行。郁结停胸。
蓄血如狂之诸证。治法不外寒凉攻下。今此舌系是应下失下之症。而见黑灰干燥之舌。急宜大承气汤以下之。已无疑义。
即《舌鉴辨正》所谓“热传三阴。则有灰黑干苔。皆当攻下泄热”者是也。但大承气以苦寒胜热之剂。倍浓朴以承气机
之变动。设或阳亢阴竭。已无气之可承。则为脉涩。直视、喘满而死矣。所以五次下之而舌色如故者。则为不治之症也。
然亦有舌心灰黑而腻者。是属胃热蒸动脾湿之症矣。故凡诊舌。不论何色。皆当辨明燥、湿、干、润之殊也。
大承气汤（方见前）
舌见黄而黑点乱生者。其症必渴谵语。脉滑者生。脉涩者死。循衣摸床者不治。若下之，见黑粪亦不治。下宜大承
气汤。
\r黄色黑点舌图\pt101a30.bmp\r
【介按】舌苔焦黄而起黑刺。症至大渴谵语。此是邪热入里。灼耗津液。病势最险。惟脉滑则邪正俱实。尚有生机。
涩则津液劫尽。即俗语所谓“灯烬油干则必死”也。至于循衣摸床。乃是阳明之坏病。故曰不治。如在险象未露之先。
欲行施治。则用大承气汤下之。服药之后。如见黑粪。此系热毒深重。渗入大肠。胃气全消。故为不治之症也。
大承气汤（方见前）
The edges of the tongue appear slightly red, while the center is grayish-black. This results from the failure to apply purgation when indicated. Da Cheng Qi Tang (Major Order the Qi Decoction) should be used for purgation. Recovery is possible once the heat subsides. If the heat persists after three or four courses of purgation, and remains unabated after five courses, it is considered incurable.
[Commentary by Jie] A grayish color on the tongue generally indicates a serious condition. These are all Interior Syndromes (Interior Syndromes: patterns indicating pathogenic factors have penetrated deep into the body) without Exterior Syndromes (Exterior Syndromes: patterns indicating pathogenic factors are at the surface of the body). There are Excess-Heat Syndromes (Excess-Heat Syndromes: conditions characterized by excess pathogenic heat), but no Deficiency-Cold Syndromes (Deficiency-Cold Syndromes: conditions characterized by deficiency of yang and cold). There may also be various syndromes such as pathogenic heat transmitting inward, epidemic diseases circulating, stagnation and knotting in the chest, and blood stasis causing manic behavior. The treatment methods do not go beyond cooling and purging. In this case, the tongue presentation corresponds to a syndrome where purgation was indicated but neglected, resulting in a black-gray, dry tongue. It is urgent to use Da Cheng Qi Tang (Major Order the Qi Decoction) for purgation, which leaves no doubt. This aligns with what *She Jian Bian Zheng* (Differentiation of Tongue Diagnosis) states: "When heat transmits to the Three Yin channels, gray-black dry coating appears, and purgation to drain heat is appropriate." However, Da Cheng Qi Tang (Major Order the Qi Decoction) is a bitter-cold formula that overcomes heat. It uses doubled Hou Po (Magnolia Bark) to facilitate the movement of Qi mechanism. If Yang is hyperactive and Yin is exhausted, leaving no Qi to support the mechanism, the pulse will become choppy, leading to death with staring eyes and wheezing fullness. Therefore, if the tongue color remains unchanged after five courses of purgation, it is an incurable syndrome. Nevertheless, there are cases where the center of the tongue is gray-black and greasy; this belongs to a syndrome of Stomach Heat steaming Spleen Dampness (Spleen Dampness: dampness generated by spleen dysfunction). Thus, whenever inspecting the tongue, regardless of color, one must distinguish between dryness, dampness, roughness, and moisture.
Da Cheng Qi Tang (Major Order the Qi Decoction) (Formula seen previously)
If the tongue surface is yellow with randomly scattered black spots, the symptoms must include thirst and delirious speech. A slippery pulse indicates survival, while a choppy pulse indicates death. The presence of picking at clothes and beds indicates an incurable condition. If purgation is administered and black stool is passed, it is also considered incurable. Purgative treatment should utilize Da Cheng Qi Tang (Major Order the Qi Decoction).
[Commentary by Jie] When the tongue coating is scorched yellow with emerging black prickles, and symptoms progress to extreme thirst and delirious speech, this indicates pathogenic heat entering the interior, scorching and consuming Body Fluids (Body Fluids: normal fluids in the body). The disease progression is most perilous. Only a slippery pulse suggests both pathogen and healthy Qi are substantial, retaining a chance of survival. A choppy pulse indicates that Body Fluids (Body Fluids: normal fluids in the body) have been completely depleted, akin to the common saying "when the lamp wick burns out and oil dries up, death is inevitable." As for picking at clothes and beds, this is a deteriorated state of Yangming Disease (Yangming Disease: a stage in Shanghan Lun characterized by excess heat in the stomach and intestines). Hence, it is termed incurable. If treatment is attempted before these critical signs manifest, Da Cheng Qi Tang (Major Order the Qi Decoction) should be used for purgation. After taking the medicine, if black stool is observed, this is because the heat toxin is severe and has penetrated the Large Intestine, causing complete exhaustion of Stomach Qi (Stomach Qi: the functional activity of the stomach). Thus, it is an incurable syndrome.
Da Cheng Qi Tang (Major Order the Qi Decoction) (Formula seen previously)