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）
舌边呈现微红色，中央为灰黑色。这是由于应当使用泻下法而未能及时使用所导致的。应使用大承气汤进行泻下治疗。热退后即可痊愈。如果必须经过三四次泻下后热势才退，若经过五次泻下后热势仍不退的，属于不治之症。
【介按】舌色出现灰色，病情通常都不轻。这都属于里证，没有表证。存在实热证，不存在虚寒证。也有邪热传入体内、时行疫病流行、郁结停滞于胸中、蓄血导致如狂等诸种证候。治疗方法不外乎寒凉攻下。如今这个舌象属于应当泻下却失于泻下的病症，而出现黑灰色干燥的舌苔，急需使用大承气汤来泻下，已无疑问。这正是《舌鉴辨正》中所说的“热邪传至三阴，就会出现灰黑干苔，都应当攻下泄热”的情况。但是大承气汤是苦寒胜热的方剂，重用厚朴以顺应气机的变动。假如阳气亢盛而阴液枯竭，已经没有气机可以顺承，就会出现脉涩、直视、喘满而死的情况。所以经过五次泻下后舌色依然如故的，就是不治之症。然而也有舌中心灰黑且腻滑的，这是属于胃热蒸动脾湿的病症。所以凡是诊察舌象，不论什么颜色，都应当辨明燥、湿、干、润的区别。
大承气汤（方剂见前文）
舌面呈现黄色并杂乱生出黑点的，其症状必定伴有口渴、胡言乱语。脉象滑利的预后良好，脉象涩滞的预后不良。出现循衣摸床症状的属于不治之症。如果使用泻下法后，排出黑色粪便的也属于不治之症。泻下治疗宜用大承气汤。
【介按】舌苔焦黄并长出黑刺，症状发展到极度口渴、胡言乱语，这是邪热入里，灼伤耗竭津液，病势最为危险。只有脉象滑利，说明邪气和正气都强实，还有生机。脉象涩滞则说明津液已被劫夺殆尽，即俗语所说的“灯油烧尽必死”。至于循衣摸床，这是阳明病的坏病，所以说是不治之症。如果在险恶征象尚未显露之前想要进行治疗，则使用大承气汤泻下。服药之后，如果出现黑色粪便，这是因为热毒深重，渗入大肠，胃气完全消亡，所以属于不治之症。
大承气汤（方剂见前文）
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)