舌见弦白心黑。脉沉微者，难治。脉浮滑者，可汗。沉实者，可下。始病即发此者，乃危殆之甚也。调胃承气汤下
之。
\r黑心舌图\pt101a14.bmp\r
【介按】此舌当作四节解之。其一。舌见沿白心黑。脉沉微者。有始病即见此舌。非由白黄变化舌转瘦小者。为真
脏中寒而寒水凌心。肾色外见。急用温剂治之。稍缓则误事。故曰难治。此即章虚谷所谓“凡黑苔，大有虚实寒热之不
同。其润而不燥。或无苔如烟煤者。正是肾水来乘心火。其阳虚极”之候也。其二。脉浮滑者。可汗。即仲景《伤寒论》
所谓“表有热、里有寒，白虎汤主之”之候也。其三。脉沉实者。可下。其舌如中黑无苔而舌底干燥有小点纹可见者。
乃胃经实热。治宜三黄白虎汤（黄连、黄芩、黄栀、石膏、知母、甘草、粳米。）亦有邪热传里。以致舌为黑色。因其热
结燥实。津液焦灼。急宜攻下其热滞以存津。故用调胃承气汤以治之。即王孟英所谓“其舌心并无黑苔。而舌根有黑苔
而燥者。宜下之”之类也。其四。始病即发此舌者。乃是寒邪直中三阴之证。其舌必润、症势险急。不及救治。故曰危
殆之甚也。
调胃承气汤（方见前）
舌尖白苔二分根黑一分者。必有身痛恶寒。如饮水不至甚者。五苓散。自汗渴者，白虎汤。下利者，解毒汤可。此
亦危殆也。
\r尖白根黑舌图\pt101a15.bmp\r
【介按】白苔带黑点。或带黑纹而粘者。此属太阴气分之湿证。故有身痛恶寒。渴不多饮之候。治宜行湿和脾。故
以五苓散主之。若自舌根黑起至尖。甚至刮之不脱。湿之不润。此时邪已化热燥耗胃液。故见自汗、口渴之证状。而用
白虎汤清胃热以治之。若热邪从阳明而转至太阴。其热愈深。其毒愈重。此时苔色转见纯黑而无芒刺矣。因其热毒无处
发泄。直奔大肠而暴下。形同下利。故宜速用解毒汤。以解肠胃之热毒为最要。然症势至此。亦危极矣。
五苓散（方见前）
白虎汤
知母（一钱五分） 甘草（炙一钱） 石膏（四钱） 糯米（一撮）
上 咀。每服一两。用水一钟半。入糯米。先煎。下诸味。再煎去渣服之。加人参亦可。
【介按】张仲景《伤寒论》内之白虎汤。有粳米而无糯米。盖糯米甘温。能收自汗。不若粳米之甘平。色白入肺。
除烦清热以止渴也。柯韵伯曰。阳明邪从热化。故不恶寒而恶热。热蒸外越。故热汗自出。热灼胃中。故渴欲饮水。邪
盛而实。故脉滑。然犹在经。故兼浮也。盖阳明属胃。外主肌肉，虽有大热而未成实。终非苦寒之味所能治也。石膏辛
寒。辛能解肌热。寒能胜胃火。寒性沉降。辛能走外。两擅内外之能。故以为君。知母苦润。苦以泻火。润以滋燥。故
以为臣。用甘草、粳米调和于中宫。且能土中泻火。作甘稼穑。寒剂得之缓其寒。苦药得之平其苦。使沉降之性。皆得
留连于味也。得二味为佐。庶大寒之品。无伤损脾胃之虑也。煮汤入胃。输脾归肺。水精四布。大烦、大渴可除矣。白
虎为西方金神。取以名汤。秋金得令而炎暑自解矣。更加人参以补中益气而生津。协和甘草、粳米之补承制石膏。知母
之寒。泻火而土不伤。乃操万全之术者也。
解毒汤
黄连（一两） 黄柏（五钱） 山栀子（二十枚） 黄芩（五钱）
上 咀。每服五钱。水一钟半。煎至一钟。去渣热服。
【介按】汪昂曰。寒极曰阴毒。热极曰阳毒。是方名曰黄连解毒。是君以黄连直解心经火毒。黄芩泻肺经火毒。黄
柏泻肾经火毒。栀子通泻三焦火毒。使诸火毒从膀胱而出也。
舌象表现为舌边呈白色、舌心发黑。若脉象沉微，病情难治；若脉象浮滑，可采用发汗法治疗；若脉象沉实，可采用泻下法治疗。若在患病初期即出现此舌象，属于极其危重的证候。可用调胃承气汤（调和胃气的承气汤）进行泻下治疗。
【介按】此舌象应当分为四种情况来解析。第一种，舌边白而舌心黑，脉象沉微者。若是患病初期就出现这种舌象，并非由白苔或黄苔变化而来，也不是因为舌体瘦小所致，而是真脏寒邪中伤，导致寒水凌犯心脏，肾色外露的征象。此时急需使用温阳药剂治疗，稍有迟缓就会延误病情，所以说“难治”。这就是章虚谷所说的：“凡是黑苔，大有虚实寒热之不同。如果舌苔湿润而不干燥，或者无苔如烟煤状，正是肾水来乘克心火，阳气极度虚弱”的证候。第二种，脉象浮滑者，可采用发汗法。这即是张仲景《伤寒论》中所说的“表有热、里有寒，用白虎汤主治”的证候。第三种，脉象沉实者，可采用泻下法。其舌象如中间发黑而无苔，且舌底干燥可见细小裂纹者，乃是胃经实热证。治疗适宜用三黄白虎汤（黄连、黄芩、黄栀子、石膏、知母、甘草、粳米）。也有因邪热传入体内，导致舌色变黑的情况，因其热结燥实，津液被煎熬灼伤，急需攻下热滞以保存津液，所以用调胃承气汤来治疗。这就是王孟英所说的“舌心并无黑苔，而舌根有黑苔且干燥者，宜用泻下法”之类。第四种，患病初期即出现此舌象者，乃是寒邪直接侵入三阴经的证候。其舌必润泽，病势险急，来不及救治，所以说“极其危重”。
舌尖部白苔占二分，根部黑苔占一分者，必定伴有身体疼痛、恶寒等症状。如果饮水不多，可用五苓散治疗；如果有自汗、口渴症状，用白虎汤治疗；如果出现腹泻，可用解毒汤治疗。这也属于危重证候。
【介按】白苔中带黑点，或带黑纹且粘腻者，这属于太阴气分的湿证。因此会有身体疼痛、恶寒、口渴但不想多饮的症状。治疗适宜祛湿健脾，所以用五苓散主治。如果黑色从舌根蔓延至舌尖，甚至刮不掉、擦不润，此时邪气已经化热，燥热耗伤胃中津液，所以出现自汗、口渴的症状，而用白虎汤清胃热来治疗。如果热邪从阳明经转至太阴经，热势越深，毒性越重，此时舌苔颜色转为纯黑而没有芒刺。因为热毒无处发泄，直奔大肠导致暴泻，形态如同下利，所以应该迅速使用解毒汤，以解除肠胃的热毒为最紧要。然而病情发展到这一步，也极其危险了。
白虎汤方解：张仲景《伤寒论》中的白虎汤，使用的是粳米而非糯米。大概是因为糯米性甘温，能收敛止汗，不如粳米性甘平，色白入肺，能除烦清热以止渴。柯韵伯说：阳明邪气从热化，所以不恶寒而恶热。热气蒸腾外越，所以热汗自出。热邪灼烧胃中，所以口渴想喝水。邪气盛而实，所以脉象滑。但病邪仍在经络，所以兼见浮脉。大概阳明属胃，主司肌肉，虽然有大热但未成实邪，终究不是苦寒药物所能治疗的。石膏辛寒，辛能解肌表之热，寒能胜胃中之火。寒性沉降，辛能走表，兼具内外之功，所以作为君药。知母苦润，苦能泻火，润能滋燥，所以作为臣药。用甘草、粳米在中焦调和，且能在土中泻火，作甘稼穑之味。寒剂得到它们可以缓和其寒性，苦药得到它们可以平抑其苦味，使沉降的药性都能停留在脾胃之中。有了这两味作为佐使，大寒的药物就不会损伤脾胃了。煮成汤剂入胃后，输布于脾，归藏于肺，水精四布，大烦、大渴即可消除。白虎是西方金神，取名以此汤，秋金得令而炎暑自然解除。再加入人参以补中益气而生津，协和甘草、粳米的补益作用，制约石膏、知母的寒性，泻火而不伤脾胃，这是万全之术。
解毒汤方解：汪昂说：寒极称为阴毒，热极称为阳毒。此方名为黄连解毒，是以黄连为君药直解心经火毒，黄芩泻肺经火毒，黄柏泻肾经火毒，栀子通泻三焦火毒，使各种火毒从膀胱排出。
The tongue presents with a white periphery and a black center. If the pulse is deep and faint, the condition is difficult to treat. If the pulse is floating and slippery, diaphoresis (sweating method) may be employed. If the pulse is deep and excess, purgation may be employed. If this tongue manifestation appears at the onset of the disease, it indicates an extremely critical and dangerous state. It should be treated with Tiaowei Chengqi Tang (Stomach-Harmonizing Purging Decoction).
[Commentary by Jie] This tongue manifestation should be interpreted in four distinct scenarios. First, when the tongue periphery is white and the center is black, accompanied by a deep and faint pulse. If this tongue appears immediately upon the onset of illness, without prior transformation from white or yellow coating, nor due to tongue shrinkage, it signifies cold pathogen directly attacking the Zang organs, causing Cold-Water to overwhelm the Heart, with Kidney color manifesting externally. Urgent treatment with warming agents is required; any delay will lead to failure. Hence, it is said to be "difficult to treat." This corresponds to Zhang Xugu's statement: "Regarding black coating, there are significant differences between deficiency/excess and cold/heat. If the coating is moist rather than dry, or if there is no coating resembling soot, it precisely indicates Kidney Water overacting on Heart Fire, representing extreme Yang deficiency." Second, when the pulse is floating and slippery, diaphoresis may be employed. This aligns with Zhang Zhongjing's *Shanghan Lun* (Treatise on Cold Damage), which states: "Heat on the exterior and Cold on the interior, Baihu Tang (White Tiger Decoction) is indicated." Third, when the pulse is deep and excess, purgation may be employed. The tongue appears black in the center without coating, and the tongue base is dry with visible fine cracks, indicating Excess-Heat in the Stomach meridian. Treatment is suitable with Sanhuang Baihu Tang (Three-Yellow White Tiger Decoction: Coptidis Rhizoma, Scutellariae Radix, Gardeniae Fructus, Gypsum Fibrosum, Anemarrhenae Rhizoma, Glycyrrhizae Radix et Rhizoma, Oryzae Fructus). In cases where pathogenic heat transmits inward causing the tongue to turn black due to heat accumulation, dryness, and excess, with fluids scorched and parched, urgent purgation is needed to remove heat stagnation and preserve fluids. Thus, Tiaowei Chengqi Tang is used. This resembles Wang Mengying's view: "If the tongue center has no black coating but the root has a dry black coating, purgation is appropriate." Fourth, if this tongue appears at the very onset of the disease, it represents Cold Pathogen directly invading the Three Yin meridians. The tongue must be moist, and the condition is perilous and acute, leaving little time for rescue. Hence, it is described as "extremely critical."
When the tip has white coating covering two parts and the root has black coating covering one part, body pain and aversion to cold are invariably present. If thirst is not severe and fluid intake is low, Wuling San (Five-Ingredient Powder with Poria) is indicated. If spontaneous sweating and thirst occur, Baihu Tang (White Tiger Decoction) is indicated. If diarrhea occurs, Jiedu Tang (Detoxification Decoction) may be used. This too is a critical condition.
[Commentary by Jie] White coating with black spots, or black streaks that are sticky, belongs to Dampness syndrome of the Taiyin Qi level. Therefore, symptoms include body pain, aversion to cold, and thirst with desire for minimal drinking. Treatment should focus on promoting dampness resolution and harmonizing the Spleen, hence Wuling San is the primary formula. If the blackness spreads from the root to the tip, becoming unscrapable and unable to be moistened, the pathogen has transformed into Heat, which is drying and consuming Stomach fluids. Consequently, symptoms of spontaneous sweating and thirst appear, and Baihu Tang (White Tiger Decoction) is used to clear Stomach Heat. If Heat pathogen shifts from the Yangming to the Taiyin, the deeper the heat, the heavier the toxicity. At this stage, the coating turns purely black without prickles. Because the Heat-Toxin has nowhere to vent, it rushes to the Large Intestine causing sudden profuse diarrhea, resembling dysentery. Rapid use of Jiedu Tang (Detoxification Decoction) to resolve intestinal Heat-Toxin is paramount. However, once the condition reaches this stage, it is extremely critical.
[Baihu Tang Analysis] In Zhang Zhongjing's *Shanghan Lun*, Baihu Tang uses Jingmi (Coix Seed/Rice Grain - specifically Oryza sativa var. japonica, often translated as Rice Grain or Glutinous Rice depending on context, here distinguished from Nuomi) rather than Nuomi (Glutinous Rice). This is likely because Nuomi is sweet and warm, capable of arresting sweating, whereas Jingmi is sweet and neutral, enters the Lung, clears irritability and heat, and stops thirst. Ke Yunbo stated: Yangming pathogens transform via Heat; thus, there is aversion to heat rather than cold. Heat steams outward, causing spontaneous hot sweat. Heat scorching the Stomach causes thirst and desire for water. Pathogen is abundant and excess, resulting in a slippery pulse. Yet, since it remains in the channels, the pulse also floats. Yangming belongs to the Stomach, governing muscles. Although there is great Heat, it has not formed solid excrement, so bitter-cold herbs alone cannot treat it. Shigao (Gypsum Fibrosum) is acrid and cold; acridity resolves muscular heat, coldness subdues Stomach fire. Cold nature sinks, acridity moves outward, mastering both interior and exterior functions, thus serving as the Sovereign herb. Zhimu (Anemarrhenae Rhizoma) is bitter and moistening; bitterness drains fire, moisture nourishes dryness, thus serving as the Minister herb. Gancao (Glycyrrhizae Radix et Rhizoma) and Jingmi harmonize in the Middle Jiao, draining fire from Earth, embodying the sweet nature of agriculture. Cold agents become milder with them; bitter drugs become less harsh with them, allowing their sinking properties to linger in the flavor. With these two as Assistant/Advisor herbs, the great cold nature does not damage the Spleen and Stomach. When decocted and entering the Stomach, it distributes to the Spleen and returns to the Lungs, spreading fluid essence, resolving great irritability and thirst. Baihu (White Tiger) is the Metal Spirit of the West; naming the decoction after it implies that when Autumn Metal rules, summer heat naturally resolves. Adding Renshen (Ginseng Radix) supplements Middle Qi and generates fluids, coordinating with Gancao and Jingmi to counteract the cold of Shigao and Zhimu, draining fire without injuring Earth, ensuring absolute safety.
[Jiedu Tang Analysis] Wang Ang stated: Extreme cold is called Yin Toxin; extreme heat is called Yang Toxin. This formula is named Huanglian Jiedu Tang (Coptis Detoxification Decoction). Huanglian (Coptidis Rhizoma) acts as the Sovereign to directly resolve Heart Meridian Fire-Toxin; Huangqin (Scutellariae Radix) drains Lung Meridian Fire-Toxin; Huangbai (Phellodendri Cortex) drains Kidney Meridian Fire-Toxin; Zhizi (Gardeniae Fructus) unblocked-drains Sanjiao Fire-Toxin, allowing all Fire-Toxins to exit via the Bladder.