\r黑尖舌图\pt101a6.bmp\r
舌见红色。尖见青黑者。水虚火实。肾热所致。宜用竹叶石膏汤治之。
【介按】伤寒传热入里。则舌苔变黑。有自舌中黑起延及尖根者。亦有自尖根黑起延至中心者。治宜急清阳明之热。
以救胃中之燥。故以竹叶石膏汤主之。倘如热邪炽甚。则变芒刺干焦。急宜犀角地黄汤去芍，加花粉、麦冬、石斛等味。
以养胃液而退邪热。庶几外可得汗而解。内可热清而愈。然亦有仿用承气之例。而急下以救液者。盖因肾为胃关。开窍
于二阴。故宜急清胃热而存肾液为治也。
竹叶石膏汤（从伤寒论新补）
竹叶（二把） 石膏（一斤） 半夏（半升洗） 麦门冬（一升） 人参（三两） 甘草（三两炙） 粳米（半升）
上水一斗。煮取六升。去滓。纳粳米。煮米熟。汤成。去米。温服一升。日三服。
【介按】此张仲景先生治伤寒解后。虚羸少气。气急欲吐之方也。张隐庵曰。“竹叶凌冬青翠。得冬令寒水之气。半
夏生当夏半。得一阴之气。参草粳米。资养胃气以生津液。麦冬通胃气之络。石膏纹肌色白。能通胃中之逆气。达于肌
腠。总令津液生而中气足。虚热解而吐自平矣。”兹治舌见红色而尖见青黑者。是清胃热而存津液也。
舌见淡红色，而中有一红晕。沿皆纯黑。乃余毒遗于心胞络之间。与邪火郁结。二火亢极。故有是症。以承气汤下之。
\r里圈舌图\pt101a7.bmp\r
【介按】舌苔淡红而起重晕者。乃是温病热毒传内之证也。热毒传内一次。舌增红晕一层。一晕尚轻。二晕为重。
三晕必死。因其邪热上乘胞络。外证必有神昏谵语。烦躁不宁。或发斑疹等证。症极危险。故先治以调胃承气汤。速清
热毒而存液也。
调胃承气汤（方见前）
炙甘草（三钱） 大黄（六钱） 硝（二钱）
上 咀，用水一钟半。先煎甘草、大黄，将熟去渣。下芒硝。再煎三五沸，顿热服。
【介按】内经云。“热淫于内。治以咸寒。火淫于内。治以苦寒。”故君以大黄之苦寒涤热。臣以芒硝之咸寒软坚。
更佐甘草之甘缓。俾留硝黄于胃中。清热而解毒也。
【黑尖舌图】
舌体呈现红色，舌尖出现青黑色。这是肾水亏虚、心火亢盛（水虚火实），由肾热所导致。适宜使用竹叶石膏汤进行治疗。
【介庵按语】伤寒病邪传变入里，舌苔便会变为黑色。有的从舌中部发黑开始，蔓延至舌尖和舌根；也有从舌尖和舌根发黑开始，蔓延至舌中部的。治疗应当紧急清除阳明经的热邪，以挽救胃中的津液干燥。因此以竹叶石膏汤为主方。如果热邪极其炽盛，舌象会变为芒刺状、干枯焦黑，此时应紧急使用犀角地黄汤，去掉芍药，加入天花粉、麦冬、石斛等药物，以滋养胃中津液并退去邪热。这样外边可以得到汗出而病解，内部可以热清而痊愈。然而也有仿照使用承气汤的例子，通过急下法来保存津液。这是因为肾是胃的关口，开窍于前后二阴，所以治疗应当紧急清除胃热以保存肾中津液。
竹叶石膏汤（出自《伤寒论》新补内容）
竹叶（两把） 石膏（一斤） 半夏（半升，洗净） 麦门冬（一升） 人参（三两） 甘草（三两，炙烤） 粳米（半升）
以上药材用水一斗，煮取六升药液，滤去药渣，加入粳米，继续煮至米粒熟透，药汁即成，滤去米粒。每次温服一升，每日服用三次。
【介庵按语】这是张仲景先生治疗伤寒病后，身体虚弱消瘦、气短不足、气逆欲吐的方剂。张隐庵说：“竹叶在冬天依然青翠，得冬季寒水之气；半夏生长于夏至前后，得一阴之气；人参、甘草、粪米，资助养胃气以生津液；麦冬疏通胃气的络脉；石膏纹理肌理色白，能通降胃中上逆之气，达于肌肤腠理。总体作用是使津液生成而中气充足，虚热解除而呕吐自然平息。”此处用于治疗舌见红色而舌尖见青黑的情况，目的是清胃热而存津液。
【里圈舌图】
舌体呈现淡红色，中间有一圈红晕，周围全是纯黑色。这是余毒遗留在心包络之间，与邪火郁结在一起，两种火气亢盛到极点，所以出现这种症状。应当用承气汤攻下治疗。
【介庵按语】舌苔呈淡红色且出现重环状红晕的，是温病热毒传入体内的证候。热毒每传入体内一次，舌头上就增加一层红晕。一层红晕尚属轻症，两层为重症，三层则必死无疑。因为邪热上乘于心包络，外在症状必然有神志昏迷、胡言乱语、烦躁不安，或者出现发斑疹等症状，病情极其危险。所以先用调胃承气汤治疗，迅速清热毒以保存津液。
调胃承气汤（方剂见前文）
炙甘草（三钱） 大黄（六钱） 硝石（二钱）
将药材切碎，用水一钟半，先煎煮甘草和大黄，快要煎好时滤去药渣，加入芒硝，再煮沸三五次，趁热一次性服用。
【介庵按语】《内经》说：“热邪淫溢于内，用咸寒之品治疗；火邪淫溢于内，用苦寒之品治疗。”所以以大黄之苦寒为君药，涤除热邪；以芒硝之咸寒为臣药，软化坚结；更佐以甘草之甘缓，使得硝石和大黄留在胃中，起到清热解毒的作用。
[Diagram of Black-Tipped Tongue]
The tongue body appears red, with the tip showing cyanotic black color. This is caused by kidney water deficiency and heart fire excess (water deficiency and fire excess), resulting from kidney heat. It is appropriate to treat with Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction).
[Mie'an's Commentary]: When pathogenic factors in Shanghan (Cold Damage) transmit inward, the tongue coating turns black. Some cases start with blackening from the center of the tongue extending to the tip and root; others start with blackening from the tip and root extending to the center. Treatment should urgently clear the heat of the Yangming channel to rescue the dryness of stomach fluids. Therefore, Zhuye Shigao Tang is used as the primary formula. If the pathogenic heat is extremely fierce, the tongue may develop prickles, becoming dry and scorched. In such cases, Xijiao Dihuang Tang (Rhinoceros Horn and Rehmannia Decoction) should be used urgently, removing Shaoyao (Paeonia lactiflora), and adding Huafen (Trichosanthes Root), Maidong (Ophiopogon Tuber), and Shihu (Dendrobium Stem), etc., to nourish stomach fluids and dispel pathogenic heat. This way, the exterior can be resolved through sweating, and the interior can heal through heat clearance. However, there are also instances following the example of Chengqi Tang formulas, using urgent purgation to preserve fluids. This is because the Kidney serves as the gate for the Stomach, opening into the two yin orifices (anterior and posterior). Thus, treatment should urgently clear stomach heat to preserve kidney fluids.
Zhuye Shigao Tang (Supplemented from Shanghan Lun):
Zhuye (Bamboo Leaves, 2 handfuls) Shigao (Gypsum Fibrosum, 1 jin) Banxia (Pinelliae Rhizoma Preparatum, half sheng, washed) Maimendong (Ophiopogonis Radix, 1 sheng) Renshen (Ginseng Radix, 3 liang) Gancao (Licorice Radix et Rhizoma, 3 liang, honey-fried) Jingmi (Oryza Sativa var. glutinosa, half sheng)
Take these herbs, add one dou of water, boil to obtain six sheng of liquid, remove the dregs, add Jingmi, and cook until the rice is ripe. The decoction is ready. Remove the rice. Take one sheng warm, three times a day.
[Mie'an's Commentary]: This is a formula by Mr. Zhang Zhongjing for treating post-Shanghan conditions characterized by emaciation, shortness of breath, air rushing upward, and nausea. Zhang Yin'an stated: "Bamboo leaves remain green in winter, absorbing the cold water energy of winter; Pinellia grows at mid-summer, absorbing the yin energy; Ginseng, Licorice, and Glutinous Rice nourish Stomach Qi to generate fluids; Ophiopogon unblocks the collaterals of Stomach Qi; Gypsum, with its white texture, descends rebellious Stomach Qi to the muscle layer. Overall, it generates fluids, strengthens middle Qi, resolves deficient heat, and stops vomiting." Here, it is used for tongues that are red with cyanotic-black tips, aiming to clear stomach heat and preserve fluids.
[Diagram of Inner-Ring Tongue]
The tongue body is pale red, with a central red halo surrounded entirely by pure black. This indicates residual toxins lingering in the Pericardium Collateral, combined with stagnant pathogenic fire, where both fires reach extreme hyperactivity, causing this symptom. It should be treated with purgation using Chengqi Tang.
[Mie'an's Commentary]: A tongue coating that is pale red with concentric red rings indicates a syndrome of Warm Disease heat-toxin transmitting inward. Each transmission of heat-toxin inward adds a layer of red ring to the tongue. One ring is mild; two rings are severe; three rings are fatal. Because the pathogenic heat ascends to the Pericardium Collateral, external symptoms must include coma, delirious speech, restlessness, or eruption of macules and papules. The condition is extremely dangerous. Therefore, Tiaowei Chengqi Tang (Regulate the Stomach and Order the Qi Decoction) is used first to rapidly clear heat-toxins and preserve fluids.
Tiaowei Chengqi Tang (Formula seen previously):
Zhi Gancao (Honey-fried Licorice Radix et Rhizoma, 3 qian) Dahuang (Rhei Radix et Rhizoma, 6 qian) Xiao (Natrii Sulfas, 2 qian)
Chop the herbs. Use one zhong and a half of water. First decoct Zhi Gancao and Dahuang. When nearly done, remove the dregs. Add Mangxiao (Natrii Sulfas). Boil for three to five boils. Take hot in one dose.
[Mie'an's Commentary]: The Neijing states: "When heat floods internally, treat with salty-cold substances; when fire floods internally, treat with bitter-cold substances." Therefore, Dahuang, bitter and cold, is used as the sovereign herb to purge heat; Mangxiao, salty and cold, is used as the minister herb to soften hardness; supplemented by Gancao, sweet and slow, to retain Mangxiao and Dahuang in the Stomach, thereby clearing heat and detoxifying.