舌见黄中黑至尖者。热气已深。两感见之。十当九死。恶寒甚者。亦死。不恶寒而下利者。可治。宜用调胃承气汤
主之。
\r黄苔黑中舌图\pt101a31.bmp\r
【介按】两感者。即阴阳俱伤、表里同病也。如太阳与少阴同病。则头痛与口干、烦满。阳明与太阴同病。则身热、
谵语与腹满、不欲食。少阳与厥阴同病。则耳聋与囊缩而厥。三阴三阳俱受病则水浆不入。昏不知人。六日当死。是即
内经所谓“其两感于寒而病者。必不免于死”之症也。兹以伤寒之邪。郁久化热。由三阳而转入厥阴。故见舌苔边黄而
中黑至尖。此时热烁肝液。内风已动。九窍将闭。本属坏症。故曰十当九死。至若恶寒亦死者。即张仲景所谓“凡厥者。
阴阳气不相顺接。便为厥。厥者。手足厥冷”是也。亦即“伤寒六七日脉微。手足厥冷、烦躁。灸厥阴，厥不还者死”
之候也。不恶寒而下利者。是阳明合并厥阴之热。渐耗肾液。致肠中燥矢迫水下流。而自利清水。故用调胃承气汤。清
胃热而下燥矢。此即张仲景所谓“少阴病。自利清水。色纯青。心下必痛。口干燥者。急下之。宜大承气汤”之症也。
调胃承气汤（方见前）
舌见外淡红心淡黑者。如恶风。表未罢。用双解散加解毒汤相半。微汗之。汗罢即下。如结胸烦躁。目直视者。不
治。非结胸者。可治。
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【介按】伤寒入里化热。由阳明而入三阴。舌即边红而中淡黑。如外证恶风者。知其表未罢也。虽云恶风。实赅恶
寒而言。盖恶风未有不兼恶寒。恶寒未有不兼恶风者。宜用双解散合解毒汤。内清外达而治之。及至汗出表解之后。审
其舌苔干燥。脐腹硬满。大便秘结者。再以承气汤下之。倘如表邪未罢之时。误用攻下之剂。因误下而热邪内陷。则为
结胸。或伤心肾之液。阴竭阳浮。以致烦躁。或伤肝液而目直视者。则为不治之症也。如若误下而致腹满时痛。未成结
胸而无烦燥。目直视等险象者，尚可设法以救之。惟有中黑而枯。并无积苔。边亦不绛。或略有微刺者。为津枯、血燥
症。急宜养液生津。不得妄用攻下之剂也。
双解散 解毒汤（二方见前）
舌苔中间呈黑色并延伸至舌尖者，表明热邪已深入。若见于两感病（同时感受表里两经之邪），十例中九例致死。若恶寒症状严重者，亦属死证。若不恶寒而伴有下利者，尚可治疗，适宜使用调胃承气汤主治。
【介按】所谓两感病，即阴阳两经俱伤、表里同病的情况。例如太阳经与少阴经同病，则出现头痛、口干、烦闷胀满；阳明经与太阴经同病，则出现身热、胡言乱语、腹部胀满、不想进食；少阳经与厥阴经同病，则出现耳聋、阴囊收缩及四肢厥冷。若三阴三阳六经均受病，则水浆难入，神志昏迷不知人，通常在第六天死亡。这就是《内经》所说的“两感于寒而患病者，必然难免于死”的病症。此处因伤寒之邪郁积日久化为热邪，由三阳经转入厥阴经，故见舌苔边缘黄而中间黑直至舌尖。此时热邪灼伤肝之津液，内风已动，九窍即将闭塞，本属于坏病（病情恶化之重症），所以说十例中九例致死。至于恶寒严重者亦死，即张仲景所说的“凡是厥证，都是阴阳之气不相顺接，便形成厥证。厥证表现为手足厥冷”，也就是“伤寒六七日，脉象微细，手足厥冷，烦躁，灸治厥阴经穴后，厥冷不回者死”的征候。不恶寒而下利的情况，是阳明经合并厥阴经的热邪，逐渐耗损肾之津液，导致肠中燥屎逼迫津液下流，从而自利清水。因此使用调胃承气汤，以清胃热并攻下燥屎。这即是张仲景所说的“少阴病，自利清水，颜色纯青，心下必定疼痛，口干燥者，应当急下之，适宜用大承气汤”的病症。（注：原文此处虽引大承气汤症，但前文主张用调胃承气汤，意在类比其急下存阴之意，或为传抄差异，此处依原文逻辑翻译）。调胃承气汤（方剂见前文）。
舌苔外部呈淡红色、中心呈淡黑色者。若伴有怕风症状，说明表证未解，应使用双解散加解毒汤各半量合用，使其微微出汗。汗出表解后即行攻下。若出现结胸（邪热与水饮互结于胸膈）且烦躁、两眼直视者，属不治之症。若非结胸者，尚可治疗。
【介按】伤寒邪气入里化热，由阳明经传入三阴经，舌象即表现为边缘红而中心淡黑。若外证有怕风表现，可知表证尚未解除。虽然说是怕风，实际上涵盖了怕寒的意思。因为怕风没有不兼带怕寒的，怕寒也没有不兼带怕风的。适宜使用双解散合解毒汤，内清里热、外达表邪以治疗。等到汗出表解之后，审视其舌苔干燥，脐腹硬满，大便秘结者，再用承气汤攻下。倘若在表邪未解之时，误用攻下的药剂，因误下导致热邪内陷，就会形成结胸；或者损伤心肾之津液，导致阴竭阳浮，以致烦躁；或者损伤肝之津液而导致两眼直视者，就属于不治之症。如果误下导致腹部胀满、时时作痛，未形成结胸且无烦躁、两眼直视等险象者，还可以设法救治。唯有舌中心黑而干枯，并无积滞之苔，边缘也不绛红，或略有芒刺者，属于津液枯竭、血液燥热的病症，应当紧急滋养津液、生津润燥，不可妄用攻下的药剂。双解散、解毒汤（两个方剂见前文）。
When the tongue coating is black in the center extending to the tip, it indicates that heat pathogen has penetrated deeply. If seen in *Lianggan* (simultaneous infection of exterior and interior meridians), nine out of ten cases are fatal. If accompanied by severe aversion to cold, it is also a death sign. If there is no aversion to cold but with diarrhea, it is treatable; *Tiaowei Chengqi Tang* (Stomach-Regulating Purging Decoction) should be used as the main treatment.
[Commentary by Jie] *Lianggan* refers to the condition where both Yin and Yang meridians are injured, and exterior and interior diseases occur simultaneously. For example, when *Taiyang* (Greater Yang) and *Shaoyin* (Lesser Yin) meridians are diseased together, symptoms include headache, dry mouth, and vexation with fullness. When *Yangming* (Bright Yang) and *Taiyin* (Greater Yin) meridians are diseased together, symptoms include body heat, delirious speech, abdominal fullness, and loss of appetite. When *Shaoyang* (Lesser Yang) and *Jueyin* (Terminal Yin) meridians are diseased together, symptoms include deafness, retraction of the scrotum, and cold limbs. If all three Yin and three Yang meridians are affected, food and fluids cannot be taken, and the patient becomes comatose and unaware; death typically occurs on the sixth day. This corresponds to the statement in the *Neijing* (Inner Canon): "Those who suffer from simultaneous cold infection will inevitably die." In this context, due to the cold pathogen stagnating for a long time and transforming into heat, moving from the Three Yang meridians into the *Jueyin* meridian, the tongue shows yellow coating on the edges and black in the center extending to the tip. At this stage, heat scorches the liver fluids, internal wind has stirred, and the nine orifices are about to close. This inherently belongs to a critical deterioration (*Huai Zheng*), hence saying nine out of ten die. Regarding those who die due to severe aversion to cold, this aligns with Zhang Zhongjing's statement: "In all cases of *Jue* (cold extremities), it is because Yin and Yang qi do not connect smoothly. *Jue* manifests as cold hands and feet." It also corresponds to the sign: "In cold damage after six or seven days, if the pulse is faint, hands and feet are cold, and there is vexation, after moxibustion on the *Jueyin* meridian, if the cold extremities do not return, death ensues." The case of no aversion to cold but with diarrhea involves heat from *Yangming* merging with *Jueyin*, gradually depleting kidney fluids, causing dry fecal matter in the intestines to force fluid downward, resulting in spontaneous purging of clear water. Therefore, *Tiaowei Chengqi Tang* is used to clear stomach heat and purge dry feces. This mirrors Zhang Zhongjing's description: "In *Shaoyin* disease, spontaneous purging of clear water, pure green color, pain in the epigastrium, and dry mouth indicate the need for urgent purging with *Dachengqi Tang*." (*Tiaowei Chengqi Tang* formula is cited previously).
When the tongue coating is pale red on the outside and pale black in the center, if accompanied by aversion to wind, it indicates that the exterior syndrome has not yet resolved. Use half doses of *Shuangjie San* (Double Release Powder) and *Jiedu Tang* (Detoxification Decoction) combined to induce slight sweating. After sweating resolves the exterior, proceed with purging. If *Jietong* (chest binding/collapse) occurs with vexation and fixed staring gaze, it is untreatable. If it is not *Jietong*, it is treatable.
[Commentary by Jie] When cold damage pathogens enter the interior and transform into heat, moving from *Yangming* into the Three Yin meridians, the tongue appears red on the edges and pale black in the center. If external signs show aversion to wind, it is known that the exterior has not resolved. Although termed aversion to wind, it actually encompasses aversion to cold, as aversion to wind invariably accompanies aversion to cold, and vice versa. One should use *Shuangjie San* combined with *Jiedu Tang* to clear heat internally and release the exterior externally. After sweating resolves the exterior, examine the tongue coating; if dry, with hardness and fullness around the navel and abdomen, and constipation, then use *Chengqi Tang* to purge. However, if purgatives are mistakenly used while the exterior pathogen remains, leading to heat sinking inward due to incorrect purging, *Jietong* may form. Alternatively, injury to heart and kidney fluids may cause yin exhaustion and yang floating, resulting in vexation; or injury to liver fluids may cause fixed staring gaze; these are untreatable conditions. If mistaken purging leads to abdominal fullness and intermittent pain without forming *Jietong*, and without dangerous signs like vexation or fixed staring gaze, rescue measures can still be attempted. Only when the center of the tongue is black and withered, lacking accumulated coating, with edges not crimson, or having only slight prickles, does it indicate dehydration and blood dryness. In such cases, nourishing fluids and generating Jin-Ye (body fluids) urgently is required, and purgative agents must not be used recklessly. (*Shuangjie San* and *Jiedu Tang* formulas are cited previously).