凡看伤寒传变。首辨舌色。则寒热虚实之理。昭然可见。如口之渴与不渴。
津之有亡枯润。色之红赤淡白。苔之黄白焦黑。刺之多少。或易刮。或刮不
去易生。肿之大小浓薄。伸缩之难易。饮之喜热喜冷。皆不可不细审也。仲
景云。邪在表不渴。传里则渴。直中三阴则口不渴。蓄血者口亦不渴。此渴
与不渴之宜辨也。汗多则液亡舌干。燥热妄投。舌亦干。湿家气不化。舌亦
干。热甚则津枯。阴竭津亦枯。此津之有无枯润宜辨也。心火旺。则舌色赤。
脾气虚。则舌淡白。此色之红赤淡白宜辨也。胸中有寒。则苔白而滑。有食。
则苔黄。热甚则苔黑。肾水竭。则苔亦焦黑。此苔之黄白焦黑宜辨也。邪热
浅则刺少。深则刺多。真阴衰亦刺多。又刺易刮者可治。刮不去易生者难
治。此刺之多少难易宜辨也。湿热甚。则舌肿大。肾液亡。则舌亦肿大。若干
且浓语不清者难治。此肿之大小浓薄宜辨也。舌虽干。易伸如常者可治。
舌缩不能伸不能言者不治。此伸缩之难易宜辨也。实渴则喜冷冻饮料。恣而
无厌。虚渴则喜热饮。少与即止。此饮之寒热多少宜辨也。以上分别。最宜
详细。而其尤要者。在兼脉与症。而察其虚实。施其补泻。他不具论。只如舌
黑焦枯。或肿或刺。群工视之不辨。而知其热症。非黄连解毒。则大小承气
下之也。殊不知脉虚数。或微细。胸腹无胀满。舌虽黑虽焦枯。虽肿虽生刺。
乃真水衰竭。不能制火。惟以六味地黄大剂饮之。虚寒。加桂附五味子。则
焦黑肿刺。涣若冰释。若芩连花粉。愈投愈甚。此予所屡见。而亲信其必然
者也。又尝治二人。入水发热。湿气大胜。舌干无津。与平胃散加葛根饮之。
舌遂生津。乃知脾胃受湿。则气不化。津无以生。用苍术以燥其湿。则气化而津生耳。
治验
一妇人发热旬余。舌干生刺。诊其脉。微细而软。按其胸腹无苦。予曰。此过
用克伐而胃气虚也。急进米饮。俟三日胃气当复。枯者可润。而刺自去
矣。且闻药则呕。若复攻之。死在旦夕。其母从之。遂以米饮进。觉甘美而
呕止舌稍和。三日而津果生。原医者来视。犹嘱曰。未可与米汤。尚宜消
导。真所谓盲人骑瞎马。半夜临深池。此辈是也。
一柴客往上海取帐。劳役而过啖。遂发寒热。及归。医与消导药三剂。舌干
而不得卧。胸中如芒刺。比余诊之。脉细而数。予曰此得之劳后使内。非
关食邪也。与六味汤二剂顿愈。
附金镜录辨舌黑治法
曾禧治郑汝东妹婿。患伤寒得黑舌。谓当用附子理中汤。人咸惊骇。遂
止。亦莫能疗。困甚。曾往视之。谓用前药。犹有生理。其家拼从之。数剂而
愈。金台姜梦辉患伤寒。亦得此舌。手足厥冷。呃逆不止。众犹作火治。几
至危殆。判院吴仁斋。用附子理中汤而愈。立斋曰。舌黑之症。有火极似
水者。即林学士所谓薪为黑炭之意也。宜凉膈散之类。以泻其阳。有水
来克火者。即曾医士所疗之人是也。宜理中汤以消阴翳。夫有是病。必
用是药。附子疗寒。其效可数。奈何世皆以为必不可用之药。宁视人之
死而不救。不亦哀哉。至于火极似水之症。用药得宜。效应不异。不可便
谓为百无一治而弃之也。
平胃散
苍术（米泔浸透切炒） 浓朴（姜汁炒） 陈皮（各一钱） 甘草（炙四分）
水煎。
附子理中汤
人参 白术（土炒） 甘草（炙） 附子（炮） 干姜（炒各等分）
水煎。
凡观察伤寒病的传变过程，首先要辨别舌色，这样寒热虚实的道理就清晰可见了。例如口是否口渴、津液是否有无枯润、舌色的红赤或淡白、舌苔的黄白焦黑、舌面刺状的多少、刺是容易刮去还是刮不去且容易再生、舌体肿胀的大小厚薄、伸缩的难易程度、饮水时喜欢热饮还是冷饮，这些都不可以不仔细审查。张仲景说：邪气在表则不渴，传入里则口渴，直中三阴经则口不渴，蓄血证也口不渴。这就是口渴与不渴需要辨别的原因。汗出过多则津液亡失导致舌干，误用燥热药物也会导致舌干，湿病患者气化功能失常也会导致舌干。热势极盛则津液枯竭，阴液竭尽津液也会枯竭。这就是津液的有无枯润需要辨别的原因。心火旺盛，则舌色红赤；脾气虚弱，则舌色淡白。这就是舌色红赤淡白需要辨别的原因。胸中有寒邪，则舌苔白而滑腻；有食积，则舌苔黄；热势极盛则舌苔黑；肾水枯竭，则舌苔也呈焦黑色。这就是舌苔黄白焦黑需要辨别的原因。邪热浅则舌刺少，邪热深则舌刺多，真阴衰败也会出现舌刺多。另外，舌刺容易刮去的可以治疗，刮不去且容易再生的难治。这就是舌刺的多少难易需要辨别的原因。湿热严重，则舌体肿大；肾液亡失，则舌体也肿大。如果舌体干枯且浓浊、言语不清的难治。这就是舌体肿胀大小厚薄需要辨别的原因。舌虽然干燥，但容易伸出如常的可以治疗；舌体收缩不能伸出、不能言语的不治。这就是舌体伸缩难易需要辨别的原因。实热口渴则喜欢冷冻饮料，贪饮不知满足；虚热口渴则喜欢热饮，少量饮用即止。这就是饮水寒热多少需要辨别的原因。以上分别辨析，最宜详细。其中尤其重要的是，结合脉象与症状，来察辨虚实，施行补泻之法，其他不再赘述。只如舌黑焦枯，或有肿胀或生刺，一般医生看不出来辨别，只知道是热证，不是用黄连解毒汤，就是用大承气汤或小承气汤攻下。殊不知如果脉象虚数，或微细，胸腹部没有胀满感，舌虽然黑虽然焦枯，虽然肿胀虽然生刺，这是真水衰竭，不能制约心火，只能用六味地黄丸大剂量服用。如果是虚寒证，加肉桂、附子、五味子，那么焦黑肿胀生刺的症状，就会像冰融化一样消散。如果用黄芩、黄连、天花粉等寒凉药，病情只会越来越重。这是我多次见到并确信无疑的。又曾经治疗两个人，入水后发热，湿气大胜，舌干无津，给予平胃散加葛根服用，舌遂生津。这才知道脾胃受湿，则气化功能失常，津液无法生成，使用苍术燥湿，则气化恢复而津液产生。
医案一则：一妇人发热十余天，舌干生刺，诊其脉象，微细而软，按压胸腹部没有痛苦。我说：这是过度使用克伐药物导致胃气虚弱。急进米汤，等待三天胃气应当恢复，枯槁的舌象可以滋润，而生刺自然去除。况且听到药味就呕吐，如果再攻伐，死期就在旦夕之间。她的母亲听从了我的建议，于是喂服米汤，觉得甘甜美味而呕吐停止，舌象稍和缓。三天后津液果然生出。原来的医生来看，还嘱咐说：不可以给米汤，还应该用消导药。这真是所谓的“盲人骑瞎马，半夜临深池”，说的就是这类人。
又一柴商去上海讨账，劳累过度且饮食不节，于是发寒热。回家后，医生给予消导药三剂，导致舌干而无法入睡，胸中如芒刺扎。等到我诊治时，脉象细而数。我说：这是劳役后房事所致，与食积无关。给予六味地黄汤两剂，顿时痊愈。
附《金镜录》辨舌黑治法：曾禧治疗郑汝东的妹婿，患伤寒出现黑舌，曾说应当用附子理中汤。人们都感到惊骇，于是停止不用，也没有人能治好。病情危重，曾禧前往诊治，说用前面的药，还有生机。家属拼死听从，服用几剂后痊愈。金台姜梦辉患伤寒，也出现这种舌象，手足厥冷，呃逆不止。众人仍然当作火证治疗，几乎危及生命。判院吴仁斋，用附子理中汤治愈。立斋说：舌黑的病症，有火极似水的，就是林学士所说的“薪为黑炭”的意思。应该用凉膈散之类，以泻其阳。有水来克火的，就是曾医士所治疗的人。应该用理中汤以消除阴翳。有什么病，必须用什么药，附子治疗寒证，其疗效可数。为什么世人都认为它是绝对不可用的药，宁愿看着人死去也不救，不也很悲哀吗？至于火极似水的病症，用药得当，效应不差，不可以就说它百无一治而放弃它。
In observing the transmission and transformation of Shanghan (Cold Damage), one must first differentiate the tongue color, so that the principles of cold, heat, deficiency, and excess become clearly visible. For instance, whether there is thirst or not in the mouth, whether body fluids are present or absent, dry or moist, whether the tongue color is red, crimson, pale, or white, whether the coating is yellow, white, scorched, or black, the number of prickles on the tongue, whether they are easily scraped off or difficult to scrape and prone to regrowth, the size and thickness of tongue swelling, the ease or difficulty of tongue extension and retraction, and whether the patient prefers hot or cold drinks, all these require careful examination. Zhang Zhongjing stated: When pathogenic factors are in the exterior, there is no thirst; when transmitted to the interior, there is thirst; when directly invading the Three Yin meridians, there is no thirst; in cases of blood stasis accumulation, there is also no thirst. This explains why it is necessary to distinguish between thirst and no thirst. Excessive sweating leads to loss of fluids and a dry tongue; indiscriminate use of drying and heating herbs also causes a dry tongue; in patients with dampness, impaired Qi transformation also results in a dry tongue. Extreme heat leads to exhaustion of body fluids; exhaustion of Yin also leads to fluid depletion. Thus, it is essential to distinguish the presence, absence, dryness, and moisture of body fluids. Hyperactive Heart Fire results in a red or crimson tongue; Spleen Qi deficiency results in a pale white tongue. Thus, it is essential to distinguish between red/crimson and pale/white tongue colors. Cold in the chest leads to a white and slippery coating; food retention leads to a yellow coating; extreme heat leads to a black coating; exhaustion of Kidney Water leads to a scorched black coating. Thus, it is essential to distinguish between yellow, white, and scorched black coatings. Superficial pathogenic heat results in few prickles; deep pathogenic heat results in many prickles; decline of True Yin also results in many prickles. Furthermore, prickles that are easily scraped off indicate a treatable condition; those that cannot be scraped off and regenerate easily indicate a difficult-to-treat condition. Thus, it is essential to distinguish the number and ease/difficulty of prickles. Severe damp-heat leads to tongue swelling; loss of Kidney fluids also leads to tongue swelling. If the tongue is dry, thick, and accompanied by unclear speech, it is difficult to treat. Thus, it is essential to distinguish the size and thickness of tongue swelling. Although the tongue is dry, if it can extend normally, it is treatable; if the tongue is retracted, unable to extend or speak, it is untreatable. Thus, it is essential to distinguish the ease or difficulty of tongue extension. Excess heat thirst leads to a preference for cold drinks, consumed greedily without satiety; deficiency heat thirst leads to a preference for hot drinks, stopping after small amounts. Thus, it is essential to distinguish the temperature and quantity of drink intake. The above distinctions should be made in detail. Most importantly, one must combine pulse diagnosis and symptoms to differentiate deficiency and excess, and apply tonification or purgation methods accordingly; other matters are not discussed here. Consider, for example, a black, scorched, and dry tongue, possibly with swelling or prickles. Many practitioners fail to differentiate this, assuming it is merely a heat syndrome, and prescribe Huanglian Jiedu Tang (Coptis Decoction for Detoxification) or Da Chengqi Tang (Major Order the Qi Decoction) / Xiao Chengqi Tang (Minor Order the Qi Decoction) for purgation. Little do they know that if the pulse is deficient and rapid, or fine and minute, and the chest and abdomen are free of distension and fullness, even if the tongue is black, scorched, dry, swollen, or prickle-covered, this indicates exhaustion of True Water failing to control Fire. In such cases, one should administer Liuwei Dihuang Wan (Six-Ingredient Rehmannia Pill) in large doses. If it is a deficiency-cold pattern, add Rougui (Cinnamon Bark), Fuzi (Prepared Aconite Root), and Wuweizi (Schisandra Fruit). Then, the scorched black, swollen, and prickle-covered tongue will dissipate like melting ice. Conversely, using cooling herbs like Huangqin (Scutellaria Root), Huanglian (Coptis Rhizome), and Huafen (Trichosanthes Root) will exacerbate the condition. I have witnessed this repeatedly and am convinced of its certainty.
I once treated two patients who developed fever after entering water, with overwhelming dampness, resulting in a dry tongue lacking fluids. I prescribed Pingwei San (Regular Stomach Powder) with Gegen (Kudzu Root), and their tongues subsequently produced fluids. This confirmed that when the Spleen and Stomach are affected by dampness, Qi transformation fails, and fluids cannot be generated. Using Cangzhu (Atractylodes Rhizome) to dry dampness restores Qi transformation and generates fluids.
Case Record 1: A woman suffered from fever for over ten days, with a dry tongue covered in prickles. Her pulse was fine, minute, and soft. Palpation of her chest and abdomen revealed no discomfort. I said, "This is due to excessive use of draining and attacking herbs, leading to Stomach Qi deficiency. Rapidly administer rice gruel. Wait three days for Stomach Qi to recover; the desiccated tongue will become moist, and the prickles will disappear naturally. Moreover, she vomits at the smell of medicine; further attack will lead to death within a day or night." Her mother followed my advice, and she was given rice gruel. She found it sweet, vomiting stopped, and the tongue became slightly relaxed. After three days, fluids indeed returned. The original physician came to examine her and still advised against rice soup, insisting on digestive-promoting herbs. This is truly what is meant by "a blind man riding a blind horse, facing a deep pool at midnight"; such practitioners fit this description.
Case Record 2: A charcoal merchant went to Shanghai to collect debts, worked excessively, and ate irregularly, subsequently developing chills and fever. Upon returning home, physicians administered digestive-promoting herbs for three doses, resulting in a dry tongue, inability to sleep, and a sensation of thorns in the chest. When I examined him, his pulse was fine and rapid. I said, "This resulted from exertion followed by sexual activity, unrelated to food stagnation." I prescribed Liujunzi Tang (Six-Gentlemen Decoction) [Note: Context implies Liuwei Dihuang Tang based on previous mention, but text says Liujunzi/Liuwei ambiguity. Given "Lao Hou Shi Nei" (exertion + sex) and kidney yin context, Liuwei Dihuang is clinically accurate, but text says "Liujunzi". However, previous paragraph mentions "Liuwei Tang". Let's stick to literal "Liujunzi Tang" or note potential typo. Actually, standard text often cites Liuwei Dihuang for this. I will translate as written: Liujunzi Tang] for two doses, and he recovered instantly. [Correction: The source text says "Liuwei Tang" in the second case? No, it says "Liuwei Tang" in the first analysis, but "Liujunzi Tang" in the second case record? Let's check source: "与六味汤二剂顿愈". It says Liuwei Tang. My draft said Liujunzi. Correcting to Liuwei Tang.] -> I prescribed Liuwei Tang (Six-Ingredient Decoction) for two doses, and he recovered instantly.
Appendix: Treatment Methods for Black Tongue from *Jin Jing Lu* (Golden Mirror of Tongue Diagnosis):
Zeng Xi treated the brother-in-law of Zheng Rudong, who suffered from Shanghan and developed a black tongue. Zeng suggested using Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction). People were shocked and refused treatment, so no one could cure him. As the condition worsened, Zeng visited again and insisted on using the aforementioned prescription, stating there was still hope for life. The family reluctantly agreed. After several doses, he recovered. Jiang Menghui from Jintai also contracted Shanghan and developed this tongue condition, with cold extremities and incessant hiccups. Others continued to treat it as a fire syndrome, nearly causing his death. Vice-Prefect Wu Renzhai cured him using Fuzi Lizhong Tang. Lizhai commented: Black tongue syndromes include "extreme heat resembling water," which Lin Xueshi referred to as "firewood turning into black charcoal." Such cases should be treated with Liangge San (Cool the Chest Powder) to drain Yang. There are also cases of "Water overcoming Fire," such as the person treated by Physician Zeng. These should be treated with Lizhong Tang to dispel Yin shadows. One must use the appropriate medicine for the disease. Aconite treats cold conditions effectively. Why do people today consider it absolutely unusable, preferring to watch people die rather than save them? Is this not tragic? As for "extreme heat resembling water," if treated correctly, the effect is no different. One should not abandon it as incurable.
Pingwei San (Regular Stomach Powder)
Cangzhu (Atractylodis Rhizoma, soaked in rice water until permeable, sliced and stir-fried)
Houpo (Magnoliae Officinalis Cortex, stir-fried with ginger juice)
Chenpi (Citri Reticulatae Pericarpium, each 1 qian)
Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried, 0.4 qian)
Decoct in water and take orally.
Fuzi Lizhong Tang (Aconite Regulate the Middle Decoction)
Renshen (Ginseng Radix)
Baizhu (Atractylodis Macrocephalae Rhizoma, stir-fried with soil)
Gancao (Glycyrrhizae Radix et Rhizoma, honey-fried)
Fuzi (Aconiti Lateralis Radix Praeparata, processed)
Ganjiang (Zingiberis Rhizoma, stir-fried, equal parts)
Decoct in water and take orally.