【纲】仲景曰。太阳中风。以火发汗。邪风被火。两阳相熏。其身发黄。阳盛则欲衄。阴虚则
小便难。但头汗出。口干咽烂。或不大便。久则谵语。甚者至哕。手足躁扰。捻衣摸床。小便利
者可治。伤寒。若吐若下后。不解。不大便。五六日。上至十余日。日晡所发潮热。不恶寒。独语
如见鬼状。若剧者。发则不识人。循衣摸床。怵惕而不安。微喘。直视。脉弦者生。涩者死。微者。
但发热谵语者。大承气汤主之。若一服利。止后服。
【目】许叔微曰。有人病伤寒。小便不利。日晡潮热。手循衣缝。两手撮空。直视喘息。医见
之皆走。此诚恶候。得之者十中九死。仲景虽有症而无法。但云脉弦者生。涩者死。已经吐下。难
以下药。谩且救之。若大便得通而脉弦者。庶可治。与小承气一服。而大便利。诸疾渐退。脉且微
弦。半月愈。或曰。下之而脉弦者生。此何意也。余曰。金匮云。循衣妄撮。怵惕不安。微喘直视。
脉弦者生。涩者死。承气汤主之。余尝观钱仲阳小儿直诀云。寻衣领及捻物者。肝热也。此症在
金匮列于阳明部。盖阳明者胃也。肝有热。淫于胃经。故以承气泻之。且得弦脉。则肝平而胃不受
克。此所谓有生之理。读仲景论。不能博通诸方书以发明隐奥。不可也。
王好古曰。许学士作循衣撮空。是肝热。风淫末疾。此论诚当。然莫若以为肺热之邪。其人
必妄言乱语。难经云。肺邪入心为谵语也。
赵嗣真曰。此条分三截看。自起句至如见鬼状一截。是将潮热谵语不恶寒不大便列为现症。下
又分两截。以辨微剧之殊。微者但发热谵语。但字为义。以发热谵语之外。别无他症。用承气。
日一服利止后服。见其热轻。犹恐过下也。
若剧者起至涩者死。此热极危症。不可不决其生死。此阳热已极。若脉弦为阴未绝。犹可下之以复
其阴。脉涩为阴绝。不必药矣。
王肯堂曰。循衣摸床。危恶之候也。有二症。一由太阳中风。以火劫汗。因成坏病。捻衣摸床。
此则小便利者生。不利者死。一由阳明里热之极。循衣摸床。此则脉弦者生。脉涩者死也。
鳌按。楼全善云。尝治循衣摸床数人。皆用大补气虚之剂。唯一人兼 振。脉代。遂于补剂中略
加桂二分。亦振止脉和而愈。此亦偏治之法耳。由于偶中。未可奉为科律也。恐医者见楼氏之语。
遽或效尤。以致杀人。故特识于此。阅者不可忽也。
【纲】张仲景说：太阳中风证，如果用火疗来发汗，邪风与火热相互熏灼，两阳相合，会导致身体发黄。阳气过盛则想要鼻出血，阴液亏虚则小便困难。仅头部出汗，口干，咽喉溃烂，或者大便不通。时间久了会出现胡言乱语（谵语），严重的甚至出现呃逆（哕）。手足躁动不安，手指捻弄衣被和床沿（捻衣摸床）。如果小便通畅，说明病情尚有转机，可以治疗。
伤寒病，如果在经过催吐或泻下治疗后，病邪仍未解除，出现大便不通，从五六天到十几天，在傍晚时分（日晡所）发作潮热，不恶寒，独自说话好像看见了鬼怪一样。如果病情严重，发作时不认识人，手循摸衣缝和床沿（循衣摸床），惊恐不安，轻微气喘，两眼直视。脉象弦的预后良好，脉象涩的预后不良。症状较轻的，只是发热、胡言乱语，用大承气汤主治。如果服用一次后大便通利，就停止后续服用。
【目】许叔微说：有人患伤寒病，小便不利，傍晚潮热，手循摸衣缝，两手向空中抓握（撮空），两眼直视，喘息。医生见到这种情况都回避逃跑。这确实是恶劣的征候，得此病者十有九个死亡。张仲景虽然有这些症状描述却无具体方药，只说脉弦的生，脉涩的死。既然已经经过吐下治疗，很难再用攻下药。姑且尝试救治。如果大便得以通畅且脉象弦，或许可以治愈。给予小承气汤一服，大便随即通利，各种疾病逐渐消退，脉象微微带弦，半个月痊愈。有人说，攻下之后脉弦者生，这是什么意思呢？我说：《金匮要略》记载：胡乱循摸衣被、惊惕不安、轻微气喘、两眼直视，脉弦者生，脉涩者死，用承气汤主治。我曾经观察钱乙《小儿直诀》中说：寻找衣领和捻弄物品的，是肝热所致。此症在金匮中列于阳明部，因为阳明就是胃。肝有热邪，淫溢于胃经，所以用承气汤泻下。且得到弦脉，说明肝气平和而不克制胃土，这就是所谓有生机的道理。研读张仲景的论述，不能广泛通达其他医书以阐明其中的深奥之处，是不行的。
王好古说：许学士认为循衣撮空是肝热，风邪侵袭四肢末端导致的疾病，这个论述确实恰当。然而不如认为是肺热之邪。这种人必定会胡言乱语，《难经》说：肺邪传入心脏导致胡言乱语。
赵嗣真说：这一条应该分三部分来看。从起句到“如见鬼状”为第一部分，是将潮热、谵语、不恶寒、大便不通列为现有症状。下面又分为两部分，以辨别病情轻重的不同。轻症的只是发热、谵语，“但”字体现了这一含义，即在发热谵语之外没有其他症状，使用承气汤，每日一服，大便通利即停服后续药物，这是看到热势较轻，还担心过度攻下伤正。
如果是重症，从起句直到“涩者死”，这是热极危重的病症，必须决断其生死。这是因为阳热已经至极，如果脉弦表示阴气未绝，还可以用攻下法来恢复阴液；如果脉涩表示阴气已绝，就不必用药了。
王肯堂说：循衣摸床是危险恶劣的征候。有两种情况。一种是由太阳中风，用火劫迫发汗，因而形成坏病，出现捻衣摸床，这种情况是小便通畅的预后良好，小便不利的预后死亡。另一种是由阳明里热至极引起的循衣摸床，这种情况是脉弦的预后良好，脉涩的预后死亡。
沈金鳌按语：楼全善说：曾经治疗过几个出现循衣摸床症状的人，都用大补气血虚损的药剂。只有一个人兼有肢体震颤，脉象代（间歇），于是在补剂中略微加入二分桂枝，结果震颤停止，脉象调和而痊愈。这也是偏颇的治疗方法罢了，由于偶然奏效，不能作为常规法则奉守。恐怕医生看到楼氏的话，就急于效仿，以致杀人，所以特别记录在此。阅读者不可忽视。
[General Principle] Zhang Zhongjing stated: In Taiyang Wind-Strike syndrome (Taiyang Fengzhong, a disease pattern caused by wind pathogen attacking the Taiyang channel), if fire therapy is used to induce sweating, the wind pathogen combines with fire. The two Yang pathogens mutually scorching each other will cause jaundice (yellowing of the skin and eyes). Excess Yang leads to epistaxis (nosebleed), while Yin deficiency leads to difficult urination. There is only sweating on the head, dry mouth, and ulceration of the throat. Or there may be constipation. After a long time, delirium (Zhenyu, incoherent speech due to high fever) occurs. In severe cases, hiccups (Hui, spasmodic contraction of the diaphragm) may appear. The hands and feet are restless and agitated, with fingers picking at clothes and bed rails (Nianyi Mochuang, a sign of extreme restlessness and loss of consciousness). If urination is smooth, the condition is treatable.
In Cold Damage (Shanghan), if after vomiting or purging the disease is not resolved, and constipation persists for five to six days up to ten-plus days, tidal fever (Chaore, fever that worsens at a specific time of day) occurs in the late afternoon (Ribu suo). There is no aversion to cold, and the patient speaks alone as if seeing ghosts. If the condition is severe, the patient becomes unrecognizable during episodes, engages in seeking at seams of clothes and touching bedsides (Xunyi Mochuang), feels terrified and uneasy, has slight panting, and fixed staring. A wiry pulse (Xian Mai) indicates survival; a choppy pulse (Se Mai) indicates death. For mild cases presenting only with fever and delirium, Da Chengqi Tang (Major Order the Qi Decoction) is the primary treatment. If one dose results in bowel movement, stop taking the remaining medicine.
[Commentary] Xu Shuwei said: Someone suffered from Cold Damage with difficult urination, afternoon tidal fever, hand movements seeking clothing seams, grasping at empty air (Cuokong, involuntary grasping movements), fixed staring, and panting. Physicians who saw this fled in fear. This is indeed a dire prognosis; nine out of ten patients die. Although Zhang Zhongjing described these symptoms without providing a specific formula, stating only that a wiry pulse implies survival and a choppy pulse implies death, and considering that after emesis and purging, it is difficult to administer purgatives again, we should attempt rescue. If the bowels open and the pulse is wiry, there is hope for cure. Administer Xiao Chengqi Tang (Minor Order the Qi Decoction) once; upon successful bowel movement, all diseases gradually recede, and the pulse becomes slightly wiry. Recovery occurs within half a month. Some ask: Why does a wiry pulse after purging indicate survival? I say: The *Jin Gui Yao Lue* states: Randomly picking at clothes, terror, uneasiness, slight panting, and fixed staring; a wiry pulse indicates survival, a choppy pulse indicates death, treated with Chengqi Tang. I have observed Qian Yi's *Xiao'er Zhijue* stating that seeking collars and fiddling with objects indicates Liver Heat. This syndrome is listed under the Yangming section in *Jin Gui*, because Yangming corresponds to the Stomach. Liver heat overflowing into the Stomach meridian is treated with purgation via Chengqi Tang. Obtaining a wiry pulse means the Liver is pacified and does not overact on the Stomach, which is the rationale for survival. One cannot study Zhang Zhongjing’s theories without broadly consulting other medical texts to elucidate hidden profundities.
Wang Haogu said: Scholar Xu identified seeking at seams and grasping as Liver Heat, a disorder of the extremities caused by Wind pathogen. This argument is indeed appropriate. However, it might be better interpreted as Lung Heat. Such patients necessarily speak incoherently. The *Nan Jing* states: When Lung pathogen enters the Heart, it causes delirium.
Zhao Sizhen said: This passage should be read in three parts. From the beginning to "as if seeing ghosts" is the first part, listing current symptoms: tidal fever, delirium, aversion to cold absent, and constipation. The following is divided into two parts to distinguish between mild and severe conditions. Mild cases present only with fever and delirium; the word "only" (Dan) emphasizes that no other symptoms exist besides fever and delirium. Chengqi Tang is used, administered once daily, stopping subsequent doses after bowel movement, indicating light heat where excessive purging is feared.
If severe, extending to "choppy pulse indicates death," this is an extremely critical heat syndrome requiring judgment of life and death. This is because Yang heat is at its extreme. If the pulse is wiry, Yin is not yet exhausted, and purgation can still be used to restore Yin. If the pulse is choppy, Yin is exhausted, and medication is unnecessary.
Wang Kentang said: Seeking at clothes and touching bedsides is a dangerous and dire sign. There are two syndromes. One arises from Taiyang Wind-Strike where fire coercion causes sweating, leading to a complicated disease (Huabing, complications arising from improper treatment), manifesting as picking at clothes. Here, smooth urination indicates survival, difficult urination indicates death. The other arises from extreme interior heat of Yangming causing seeking at clothes and touching bedsides. Here, a wiry pulse indicates survival, a choppy pulse indicates death.
Shen Jin'ao's Note: Lou Quanshan said: He treated several patients with seeking-at-clothes-and-touching-bedsides using major Qi and Blood tonifying formulas. Only one patient also had tremors and a intermittent pulse (Dai Mai). He added a small amount of Guizhi (Cinnamon Twig) to the tonifying formula, resulting in cessation of tremors, harmonization of the pulse, and recovery. This is a biased treatment method, effective only by chance, and should not be established as a standard rule. I fear physicians might imitate this blindly based on Lou's words, leading to fatal errors, so I record this specifically. Readers must not ignore this.