朱丹溪谓∶前人以刚、柔二痉分属风湿者，非也，当以虚实分之。刚痉属外感，宜栝蒌
桂枝
葛根汤及承气汤之类；柔痉属内伤，宜四物、八物、补中益气之类。愚按∶此明暗参半之论
也。刚柔二痉，皆属于实，其虚痉乃别一证，不得以柔痉当之。盖有风寒之痉，有湿热之痉
，有产后之痉，有热病之痉。风寒之痉，是风寒凝滞津液，筋脉不能濡润舒缓，寒性收引，
故拘急也。湿热之痉者，即《内经》所谓湿热不攘，大筋痉短，小筋弛长，痉短为拘，弛长
为痿者也；产后之痉，虽由血虚，亦由风寒，若不伤风寒者，即血虚不能成痉。故风寒之痉
，有刚有柔，寒盛为刚，风盛而内热，即为柔也；湿热之痉，有柔无刚，二者体各不同，同
归于实。惟热病之痉，《灵枢·热病篇》曰∶热而痉者，腰折螈 ，口噤齿 也。此则津枯
血败，筋无所养之败证也，谓之虚痉，而何有刚柔之辨耶?徐灵胎谓痉为伤寒坏病，仲景
诸
方，未尝一效。是不知刚柔二痉之病情，而并不知虚痉之治法也。风寒之痉，属于太阳，即
产后风寒，亦太阳也，桂枝葛根主之，产后佐以养血可矣。湿热之痉，与热病之痉，有属于
阳明内实者，承气主之；其热病之属于厥阴者
，是肾水枯而肝风逆乱也，四物尚不对证，岂仲景实证诸方可施者乎?拟大剂生地，少加桃
仁擂浆冲服，或再加防风。仲景猪肤汤法，亦可用。夫虚实者，以体气言也；刚柔者，以病
形言也。刚柔二字，只以分风寒、湿热之轻重，若细求之，即刚痉，亦何尝不由津气之不足
?津充气旺，即风寒深入，亦何至成痉耶?
痉有寒湿外束，阳气内伏而然者，脉紧、无汗是也。有寒湿下冲，阳气上格而然者，面
赤、足冷是也。其证颇与香港脚相类。香港脚有冲心者，是寒湿由下从气化而上冲于里，此乃循
经络而上冲于表也。上下之升降既格，表里之嘘吸亦闭，而大气 郁于脉中矣，故脉伏而坚
直也。脉沉细者，阳气内伏也。脉 如蛇，腹暴胀大，为欲解者，必其脉由沉细变见粗长
而软，是湿中生热，有温润之意。津液渐见流通，阳气之机拨动，与寒湿战于中焦，故相激
而为腹胀也。此乃刚痉由阴化阳之转关也，与柔痉无涉，与虚痉更无涉。
仲景论列痉证多条，并不执定刚、柔二字。读者须就各条，研究其义，不可专以刚、柔
二字
横住胸中。夫病痉者，其人平日必湿重而气滞，或血燥而气涩也；平日已有不能运化津液濡
养筋脉之势，及风寒伤之，无汗而津愈凝矣；风温伤之，多汗而津愈耗矣。此初起病即见痉
者也。大致一缓不复痉者，为轻；时缓时急，一日数见者，为重；在经与入里之分也。发热
二三日而痉者，如未见汗，筋骨疼痛，仍即刚痉也；已见汗，有阳明内实证者，仍即柔痉也
；病久而痉，表里证俱不见者，气败而津枯血燥之死证也。其证必时缓时急，时迷时醒。盖
凡痉者，多兼见厥，痉之实者，昏迷反甚，而口开手紧；痉之虚者，谵妄无常，而口开手撒
，如中风绝证也。中风有见痉者，有不见痉者，痉有因风者，有不因风者。前人或以痉即中
风者，亦谬也。又有身俯不抑，四肢蜷曲，头膝相抵者，在新感为邪中阳明，在久病为阳
明
虚竭。阳明为气血之海，而五脏六腑之所禀也。困败如此，脏腑何所禀而活耶?较之反张上
窜者，尤为难治，而其死尤速也。
朱丹溪说：前人将刚痉和柔痉分别归属于风湿的说法，是不对的，应当以虚证和实证来区分。刚痉属于外感病，适宜使用栝蒌桂枝葛根汤以及承气汤之类的方剂；柔痉属于内伤病，适宜使用四物汤、八物汤、补中益气汤之类的方剂。我按语认为：这是半明半暗的言论。刚痉和柔痉，都属于实证，所谓的虚痉乃是另一种证候，不能拿柔痉来充当它。大概有风寒引起的痉病，有湿热引起的痉病，有产后引起的痉病，有热病引起的痉病。风寒引起的痉病，是风寒凝滞了津液，导致筋脉不能得到濡润而舒缓，寒性具有收引的特性，所以出现拘急痉挛。湿热引起的痉病，就是《内经》所说的湿热不除，大筋收缩变短，小筋松弛变长，收缩变短表现为拘挛，松弛变长表现为痿软；产后引起的痉病，虽然由血虚引起，但也兼夹风寒，如果不感受风寒，仅仅是血虚是不会形成痉病的。所以风寒引起的痉病，有刚痉也有柔痉，寒邪盛重为刚痉，风邪盛重且伴有内热，就称为柔痉；湿热引起的痉病，只有柔痉没有刚痉，两者的病体各不相同，但都归于实证。唯有热病引起的痉病，《灵枢·热病篇》说：发热并出现痉病的人，会出现腰背反折、抽搐、牙关紧闭、咬紧牙齿的症状。这则是津液枯竭、血液败坏的筋脉失去滋养的败坏证候，称之为虚痉，哪里还有什么刚柔的区别呢？徐灵胎认为痉病是伤寒的坏病，张仲景的各种方剂，没有一个是有效的。这是不了解刚痉和柔痉的病情，并且也不了解虚痉的治疗方法。风寒引起的痉病，属于太阳经病变，即使是产后感受风寒，也属于太阳经病变，用桂枝葛根汤为主治疗，产后辅助以养血药物就可以了。湿热引起的痉病和热病引起的痉病，有属于阳明腑实证的，用承气汤为主治疗；那些热病属于厥阴经的，是肾水枯竭而肝风逆乱，四物汤尚且不对证，难道是张仲景治疗实证的那些方剂可以施用的吗？我拟用大剂量的生地黄，少量加入桃仁研磨成浆冲服，或者再加防风。张仲景猪肤汤的方法，也可以使用。所谓虚实，是从体质元气来说的；所谓刚柔，是从病症形态来说的。刚柔这两个字，只用来区分风寒和湿热的轻重程度，如果仔细推求，即使是刚痉，又何尝不是由于津气和元气的不足呢？如果津液充足、元气旺盛，即使风寒深入体内，又怎么会形成痉病呢？
痉病有因寒湿外束、阳气内伏而导致的，其脉象紧、无汗，就是这种情况。有因寒湿下冲、阳气上格（阻隔）而导致的，其面色赤红、足部寒冷，就是这种情况。这些症状颇与香港脚（脚气病）相似。香港脚有冲心的情况，是寒湿从下部通过气化作用向上冲击于里，这里是沿着经络向上冲击于表。上下升降之气既已格拒不通，表里呼吸之气也闭塞，导致大气郁结在脉管之中，所以脉象潜伏而坚直。脉象沉细的，是阳气内伏的表现。脉象像蛇一样蜿蜒曲折，腹部突然胀大，如果是即将痊愈的征兆，必然是脉象由沉细变为粗长而柔软，这是湿中生热，带有温润的意思。津液逐渐流通，阳气的机转被拨动，与寒湿在中焦交战，所以相互激荡而产生腹胀。这是刚痉由阴证转化为阳证的转折点，与柔痉无关，与虚痉更无关。
张仲景论述列举痉证的多条内容，并不固执地限定刚、柔这两个字。读者必须针对各条内容，研究其中的义理，不可专门将刚、柔二字横亘在心中。患痉病的人，平日必定湿气重而气机阻滞，或者血燥而气机涩滞。平日就已经有不能运化津液以濡养筋脉的趋势，等到风寒侵袭，无汗而津液更加凝滞；风温侵袭，多汗而津液更加耗损。这是初起病时就出现痉病的。大致而言，发作一次后缓解不再发痉的，为轻症；时缓时急，一天发作数次的，为重症；这是在经脉与入里的区别。发热二三天后出现痉病，如果未见出汗，筋骨疼痛，仍然就是刚痉；已经出汗，且有阳明腑实证表现的，仍然就是柔痉；患病日久才出现痉病，表证和里证都不见的，是气败津枯血燥的死证。这种病症必定时缓时急，时而昏迷时而清醒。大概凡是痉病，多兼见厥证，痉病实证者，昏迷反而严重，且口开手紧握；痉病虚证者，谵语妄言无常，且口开手松开，如同中风绝证。中风有出现痉病的，有不出现痉病的，痉病有因风邪引起的，有不因风邪引起的。前人有的认为痉病就是中风，这也是错误的。又有身体前俯无法仰起，四肢蜷曲，头膝相抵的情况，在新感病中是邪气中伤阳明经，在久病中是阳明经气血虚竭。阳明经是气血的海源，也是五脏六腑禀受气血的地方。困顿败坏到如此地步，脏腑靠什么禀受气血而存活呢？比起身体反张向上窜动的情况，更加难以治疗，而且死亡速度更快。
Zhu Danxi stated: The previous practice of attributing Gang-Jing (Stiff Spasm) and Rou-Jing (Soft Spasm) to Wind-Dampness is incorrect; they should be differentiated by Deficiency (Xu, 虚) and Excess (Shi, 实). Gang-Jing belongs to External Contraction (Wai-Gan, 外感), suitable for formulas such as Gualou Guizhi Gegen Tang (Trichosanthes Root, Cinnamon Twig, and Pueraria Decoction) and Chengqi Tang (Descending the Qi Decoction); Rou-Jing belongs to Internal Injury (Nei-Shang, 内伤), suitable for formulas such as Siwu Tang (Four Substances Decoction), Bawu Tang (Eight Substances Decoction), and Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction). I note: This is a half-clear, half-obscure argument. Both Gang-Jing and Rou-Jing belong to Excess patterns; so-called Xu-Jing (Deficiency Spasm) is a distinct syndrome and cannot be equated with Rou-Jing. Generally, there are Jing caused by Wind-Cold, Jing caused by Damp-Heat, Jing occurring postpartum, and Jing resulting from Febrile Diseases (Re-Bing, 热病). Jing caused by Wind-Cold arises when Wind-Cold stagnates Body Fluids (Jin-Ye, 津液), preventing the sinews and vessels from being moistened and relaxed; since Cold has a contracting nature, spasm and tightness occur. Jing caused by Damp-Heat corresponds to what *The Inner Canon* describes as "when Damp-Heat is not dispelled, the large sinews become contracted and short, while the small sinews become lax and long"; contraction leads to spasm, while laxity leads to Wei syndrome (flaccidity). Postpartum Jing, although caused by Blood Deficiency, also involves Wind-Cold; without Wind-Cold invasion, Blood Deficiency alone does not form Jing. Thus, Wind-Cold-induced Jing can be either Gang or Rou: severe Cold constitutes Gang-Jing, while dominant Wind with internal Heat constitutes Rou-Jing. Damp-Heat-induced Jing has only Rou characteristics, not Gang; their pathological bodies differ, yet both fall under Excess. Only Jing caused by Febrile Diseases, as stated in *Ling Shu: Re Bing Pian*: "When heat accompanies spasm, there is opisthotonos, convulsions, trismus, and clenched teeth." This represents a critical failure where Body Fluids are depleted and Blood is ruined, leaving sinews without nourishment; this is called Xu-Jing, where does the distinction of Gang and Rou apply? Xu Lingtai claimed that Jing is a deteriorated disease of Shanghan (Cold Damage), and none of Zhang Zhongjing's formulas were effective. This demonstrates ignorance of the pathology of Gang and Rou Jing, and even more so, ignorance of the treatment methods for Xu-Jing. Wind-Cold-induced Jing belongs to the Taiyang (Greater Yang) channel; even postpartum Wind-Cold belongs to Taiyang, treated primarily with Guizhi Gegen Tang, supplemented by blood-nourishing herbs for postpartum cases. Damp-Heat-induced Jing and Febrile Disease-induced Jing may involve Yangming Interior Excess, treated with Chengqi Tang; those Febrile Disease-induced Jing belonging to Jueyin (Terminal Yin) involve depletion of Kidney Water and chaotic Liver Wind, for which Siwu Tang is inappropriate, let alone Zhang Zhongjing's formulas for Excess patterns. I propose using a large dose of Sheng Di Huang (Rehmanniae Radix), mixed with crushed Tao Ren (Persicae Semen) taken as a slurry, possibly adding Fang Feng (Saposhnikoviae Radix). Zhang Zhongjing's Zhufu Tang (Pig Skin Decoction) method may also be applicable. "Excess" and "Deficiency" refer to constitutional vitality; "Gang" and "Rou" refer to clinical manifestations. These terms merely distinguish the severity of Wind-Cold versus Damp-Heat. Upon closer examination, even Gang-Jing stems from insufficiency of Jin-Qi (Fluids and Vital Qi). If fluids are abundant and Qi is vigorous, even deep penetration by Wind-Cold would not result in Jing.
There are cases of Jing caused by external constraint of Cold-Dampness and internal entrapment of Yang Qi, characterized by a tight pulse and absence of sweating. There are cases caused by downward rushing of Cold-Dampness and upward obstruction of Yang Qi, characterized by facial redness and cold feet. These symptoms resemble Hong Kong Foot (Jiao Qi, foot-and-mouth disease/beriberi). In Hong Kong Foot, there is a type that rushes to the heart, where Cold-Dampness rises from below via Qi transformation into the interior; here, it ascends along the meridians to the exterior. With the blockage of ascending and descending movements, and the closure of interior-exterior respiration, the Great Qi becomes stagnant within the vessels, resulting in a hidden, firm, and straight pulse. A deep and fine pulse indicates internal entrapment of Yang Qi. A pulse resembling a snake, accompanied by sudden abdominal distension, suggests impending resolution if the pulse changes from deep/fine to coarse/long and soft; this indicates Heat generated within Dampness, possessing a warming and moistening quality. As Body Fluids gradually circulate and the mechanism of Yang Qi is activated, it battles Cold-Dampness in the Middle Jiao, causing agitation and abdominal distension. This is the turning point where Gang-Jing transforms from Yin to Yang, unrelated to Rou-Jing or Xu-Jing.
Zhang Zhongjing listed multiple descriptions of Jing syndromes without rigidly adhering to the terms "Gang" and "Rou." Readers must study the meaning of each description and not keep these two terms fixed in their minds. Patients suffering from Jing typically have heavy Dampness and stagnant Qi, or dry Blood and sluggish Qi in daily life. They already possess a tendency to fail to transform Body Fluids and nourish sinews. When invaded by Wind-Cold, lack of sweat causes further stagnation of fluids; when invaded by Wind-Warmth, excessive sweating causes further depletion of fluids. This describes Jing appearing at the onset of illness. Generally, if the spasm relaxes and does not recur, it is mild; if it alternates between relaxation and tension, occurring several times a day, it is severe, distinguishing involvement of the meridians from entry into the interior. If Jing appears after two to three days of fever, without sweating and with bone/joint pain, it remains Gang-Jing; if sweating has occurred and Yangming Interior Excess signs are present, it remains Rou-Jing. If Jing appears after prolonged illness without exterior or interior signs, it is a fatal syndrome of Qi collapse, fluid depletion, and dry blood. Symptoms include alternating relaxation and tension, and alternating coma and consciousness. Generally, Jing often accompanies Jue (cold extremities/collapse); in Excess Jing, coma is severe with open mouth and clenched hands; in Deficiency Jing, there is delirious speech with an open mouth and relaxed hands, resembling the terminal stage of Stroke (Zhong Feng, 中风). Stroke may present with Jing or without; Jing may be caused by Wind or not. It is erroneous for predecessors to equate Jing directly with Stroke. There are also cases where the body bends forward uncontrollably, limbs curl, and head touches knees; in acute onset, this is pathogenic factor invading the Yangming channel; in chronic illness, it is exhaustion of Yangming Qi and Blood. Yangming is the sea of Qi and Blood and the source for all Zang-Fu organs. If exhausted to this degree, how can Zang-Fu survive? Compared to opisthotonos with upward thrusting, this is even harder to treat and leads to death more rapidly.