中风最宜辨闭脱二证。闭证口噤目张，两手握固，痰气壅塞，语言謇涩，宜用开窍通络
、清
火豁痰之剂，如稀涎散、至宝丹之类。脱证口张目合，手撒遗尿，身僵神昏，宜用大补之剂
，如参附汤、地黄饮子之类。然闭证亦有目合遗尿、身僵神昏者，惟当察其口噤、手拳、面
赤、气粗、脉大以为别。脱证亦有痰鸣不语者，惟当辨其脉虚大以为别。至于闭证气塞，亦
有六脉俱绝者，不得以无脉而遂谓是脱证也。
徐灵胎《伤寒类方》白头翁汤注云∶凡下重者，皆属于热。按∶《金匮要略》云∶小肠
有寒
者，其人下重便血。是则下重不专属于热矣，特热证较多，当察脉证治之，不可执一。阳明
主阖，故其病为胃家实。太阴主开，故其病为自利。胃家实者，是胃液燥竭也，故必渴，药
用栀、豉、白虎、人参、竹叶、石膏、承气等，以存津为主。自利者，是脾脏寒湿也，故不渴
，药用理中、四逆等温中为主。
《伤寒论》桃花汤证，或以为寒，或以为热，或以为寒热不调，或以为先热后寒，持论
不一
，独沈棣怀《医学三书论》至为详确，备录之。阳病下利，便脓血，协热也。阴病下利，便
脓血，下焦不约而里热也。与桃花汤固下散寒，成氏此注深合仲景之旨。盖少阴传经阴病，
病于少阴之经，实结于胃，少阴直中之寒证，病在本脏，下焦虚寒失闭藏之职，故用温补以
散里寒而固肠胃。《准绳》反以成氏释里寒为非，岂不思热而用固肠收涩之剂，则热何由去
耶？吴缓谓此症三阳传来，纯是热病，赤石脂性寒，假干姜以从治之。彼盖见血为热，不知
有形之血，必赖无形之气以固之，下焦虚寒不能固血，非温补不能助阳以摄阴，何必阳病热
而始便脓血哉？赤石脂性温，丹溪、东垣皆云，然吴缓何据而谓其寒？喻昌颇知仲景救阳之意
，而于此条亦以为热证，乃云滑脱即不可用寒药，何以仲景于自下利者，多用黄芩、黄连耶
？白头翁又何为耶？其注支离矛盾，学人当细详之。（以HT 按∶下利热多寒少，其辨少阴寒利
之法，汪苓友《伤寒辨证广注》言之最悉，附录于此少阴里寒，便脓血，色必黯而不鲜，乃
肾受寒湿之邪，水谷之津液为其凝泣，酝酿于肠胃之中，而为脓血，非若火性急速而色鲜明
，盖冰气静而腹喜就温，欲得手按之而腹痛乃止。）
中风病最应当辨别闭证和脱证这两种证候。闭证表现为牙关紧闭、眼睛睁开、双手紧握成拳、痰气壅塞阻滞、言语不清，适宜使用开窍通络、清火豁痰的方剂，如稀涎散、至宝丹之类。脱证表现为嘴巴张开、眼睛闭合、手松无力、遗尿、身体僵硬、神志昏迷，适宜使用大补元气的方剂，如参附汤、地黄饮子之类。然而，闭证中也有出现眼睛闭合、遗尿、身体僵硬、神志昏迷的情况，只应当观察其是否有牙关紧闭、手握拳、面色红赤、呼吸粗重、脉象洪大来加以区别。脱证中也有出现喉间痰鸣、不能说话的情况，只应当辨别其脉象是否虚大来加以区别。至于闭证导致的气机闭塞，也有出现六脉俱无的情况，不能因为没有脉搏就认为是脱证。
徐灵胎在《伤寒类方》中对白头翁汤的注释说：凡是伴有里急后重的症状，都属于热证。按：《金匮要略》中说：小肠有寒邪的人，会出现下重便血的症状。这说明下重并不专属于热证，只是热证较多，应当根据脉象和症状进行治疗，不可固执一端。阳明经主司阖降，所以它的病证是胃家实（胃肠燥热结实）。太阴经主司开泄，所以它的病证是自利（自发性腹泻）。所谓胃家实，是指胃中津液干燥枯竭，所以必定口渴，用药以栀子、豆豉、白虎汤、人参、竹叶、石膏、承气汤等为主，以保存津液为主要目的。所谓自利，是指脾脏寒湿内盛，所以不口渴，用药以理中汤、四逆汤等温中散寒为主。
《伤寒论》中桃花汤证的性质，有人认为是寒证，有人认为是热证，有人认为是寒热不调，有人认为是先热后寒，观点不一。唯独沈棣怀在《医学三书论》中的论述最为详细确切，现全文录于此。阳病下利，大便带脓血，这是协热利（伴随发热的下利）。阴病下利，大便带脓血，这是下焦约束无力而导致的里热。用桃花汤固涩止泻、散除里寒，成无己的这一注释深得张仲景的本意。大概少阴经传变的阴病，病位在少阴经脉，实则结聚于胃；少阴直中的寒证，病位在本脏，下焦虚寒失去闭藏的功能，所以用温补的方法来散除里寒并固护肠胃。《准绳》反而认为成无己解释为里寒是错误的，难道不想想如果热证却使用固肠收涩的药剂，那么热邪如何能去除呢？吴缓说此症是从三阳经传来，纯粹是热病，赤石脂性寒，借干姜的性质来从治（反佐治疗）。他大概是见到出血就认为是热，却不知道有形的血液，必须依赖无形的气来固摄，下焦虚寒不能固摄血液，非温补不能助阳气以统摄阴血，何必一定是阳病热证才会便脓血呢？赤石脂性温，朱丹溪、李东垣都这样说，但吴缓有什么依据说它性寒？喻昌很懂得张仲景救阳的意图，但在此条中也认为是热证，还说滑脱不禁时不可用寒药，为什么张仲景对于自下利的情况，多用黄芩、黄连呢？白头翁汤又作何解释呢？他的注释支离破碎、自相矛盾，学习的人应当仔细详察。（以HT按：下利热多寒少的情况，辨别少阴寒利的方法，汪苓友在《伤寒辨证广注》中说得最详尽，附录于此：少阴里寒，便脓血，颜色必定暗滞而不鲜明，这是肾受寒湿之邪，水谷的津液被凝滞，酝酿在肠胃之中，形成脓血，不像火性急速而颜色鲜明，大概冰气静敛而腹部喜欢温暖，想要用手按压腹部疼痛才能停止。）
Zhongfeng (Stroke) most requires differentiation between the Bi Syndrome (Closed Syndrome) and Tuo Syndrome (Open/Deficiency Syndrome). The Bi Syndrome presents with locked jaws, open eyes, clenched fists, phlegm-qi obstruction, and slurred speech; it is suitable for formulas that open orifices and unblock collaterals, clear fire, and resolve phlegm, such as Xixian San (Saliva-Thinning Powder) and Zhibao Dan (Precious Treasure Pill). The Tuo Syndrome presents with open mouth, closed eyes, relaxed hands, urinary incontinence, rigid body, and coma; it is suitable for major tonifying formulas, such as Shenfu Tang (Ginseng and Aconite Decoction) and Dihuang Yinzi (Rehmannia Infusion). However, there are cases of Bi Syndrome presenting with closed eyes, urinary incontinence, rigid body, and coma; these must be distinguished by observing for locked jaws, clenched fists, reddish face, coarse breathing, and a large pulse. There are also cases of Tuo Syndrome presenting with gurgling phlegm and inability to speak; these must be distinguished by identifying a deficient and large pulse. As for Qi obstruction in Bi Syndrome, there are cases where all six pulses are absent; one must not conclude it is Tuo Syndrome simply due to the absence of pulse.
Xu Lingtai, in his annotation of Baitouweng Tang (Coptis Decoction) in *Shanghan Leifang* (Classification of Formulas for Cold Damage), stated: "All cases of tenesmus belong to Heat." Note: *Jingui Yaolue* (Essential Prescriptions from the Golden Cabinet) states: "When there is cold in the Small Intestine, the person experiences tenesmus and bloody stool." This indicates that tenesmus does not exclusively belong to Heat; rather, Heat patterns are more common. Treatment should be based on pulse and symptoms, and one must not adhere rigidly to a single view. Yangming governs closing, so its disease is Weijia Shi (Stomach-Fu Excess/Heat Constipation). Taiyin governs opening, so its disease is Zili (Spontaneous Diarrhea). Weijia Shi refers to the dryness and exhaustion of Stomach fluids, so thirst is inevitable; medications such as Zhizi (Gardeniae Fructus), Chichi (Perillae Folium), Baihu Tang (White Tiger Decoction), Renshen (Ginseng Radix et Rhizoma), Zhuyeqing (Bamboo Leaf), Shigao (Gypsum Fibrosum), and Chengqi Tang (Purgative Decoction) are used, primarily to preserve body fluids. Zili refers to Cold-Dampness in the Spleen, so there is no thirst; medications such like Lizhong Tang (Regulate the Middle Decoction) and Sini Tang (Frigid Extremities Decoction) are used, primarily to warm the middle.
Regarding the Zheng (Syndrome) of Taohua Tang (Peach Blossom Decoction) in *Shanghan Lun* (Treatise on Cold Damage), opinions vary: some consider it Cold, some Heat, some Cold-Heat disharmony, and some initial Heat followed by Cold. Shen Dihuai’s discussion in *Yixue Sanshu Lun* (Discussions on Three Books of Medicine) is particularly detailed and accurate, so it is recorded here. For Yang disease diarrhea with pus and blood, this is Xi Re Li (Diarrhea accompanying Heat). For Yin disease diarrhea with pus and blood, this is due to the lower Jiao's failure to constrain, resulting in interior Heat. Using Taohua Tang to consolidate the lower Jiao and scatter Cold aligns deeply with Zhang Zhongjing’s intent. Generally, Shaoyin transmitted Yin disease affects the Shaoyin meridian but actually knots in the Stomach; Shaoyin direct invasion Cold disease affects the Zang organ itself, where lower Jiao deficiency-cold loses its function of closure and storage. Thus, warming and tonifying methods are used to scatter interior Cold and secure the intestines and stomach. *Zhuanshen* (Compendium) incorrectly claims that Cheng Wuji’s explanation of interior Cold is wrong. Does it not occur to them that if Heat is present, using astringent intestinal-stopping agents would prevent the Heat from exiting? Wu Huan stated that this syndrome comes from the Three Yang meridians and is purely a Heat disease; since Chishizhi (Halloysitum Rubrum) is Cold-natured, Ganjiang (Zingiberis Rhizoma) is used to treat it via reverse synergy (fan zhi). He likely saw bleeding and assumed Heat, unaware that tangible Blood relies intangible Qi to hold it. Lower Jiao deficiency-cold cannot secure Blood; only warming and tonifying can assist Yang to control Yin. Why must it be Yang disease Heat before pus and blood appear? Chishizhi is Warm-natured, as Zhu Danxi and Li Dongyuan both stated. On what basis did Wu Huan claim it is Cold? Yu Chang understood Zhang Zhongjing’s intent to rescue Yang, yet he considered this clause a Heat syndrome, stating that when slipping/descending occurs, Cold medicines must not be used. Why then does Zhang Zhongjing frequently use Huangqin (Scutellariae Radix) and Huanglian (Coptidis Rhizoma) for spontaneous diarrhea? What about Baitouweng Tang? His annotations are fragmented and contradictory; students should examine them carefully. (Note by HT: In cases of diarrhea with more Heat than Cold, the method for differentiating Shaoyin Cold diarrhea is explained most thoroughly by Wang Lingyou in *Shanghan Bianzheng Guangzhu* (Expanded Annotations on Differentiation of Cold Damage Syndromes), appended here: Shaoyin interior Cold causing pus and blood in stool will have a dark, dull color, not bright. This is because the Kidney has received Cold-Damp pathogenic factors, condensing the fluids of food and drink, which ferment in the intestines and stomach to form pus and blood. This differs from Fire nature, which is rapid and produces bright colors. Ice energy is still, and the abdomen prefers warmth; pain stops only when pressed by hand.)