循衣摸床危恶之候也有二证其一由太阳中风以火劫汗因成坏病捻衣摸床小便利者生不利者死其一由阳明里热之极
循衣摸床脉弦者生涩者死
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退场门干咽烂或不大便久则谵语甚者
至哕手足躁扰捻衣摸庆小便利者可治（详头汗）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（成 若吐若下皆伤胃气不大便五六日上至十余日者亡津液胃气虚邪热内结也阳明旺于申酉戌日晡所发潮热热者
阳明热甚也不恶寒者表证罢也独语如见鬼状者阳明内实也以为热气有余若剧者是热气太甚也热太甚于内昏冒正气使不
识人至于循衣摸床惕而不安微喘直视伤寒阳胜而阴绝者死阴胜而阳绝者死热剧者为阳胜脉弦为阴有余脉涩为阴不足阳
热虽剧脉弦知阴未绝而犹可生脉涩则绝阴故不可治其邪热微而未至于剧者
但发热谵语可与大承气汤以下胃中热经曰凡服下药中病即止不必尽剂此以热未剧故云若一服利则止后服 〔赵〕此段当
分作三截看自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止为上一截是将潮热谵
语不恶寒不大便对为现证下文又分作一截以辨剧者微者之殊微者但发热谵语但字为义以发热谵语之外别无他证其用承
气汤日一服利止后服见其热轻犹恐下之太过也至于剧者发则不识人循衣摸床惕而不安微喘直视如此热极证危不可不决
其死生以断之以脉弦者生涩者死此阳热已极若脉弦为阴未绝犹可下之以复其阴若脉涩为阴绝不可药而必死矣今活人书
但言剧者而去其微者二字混两证通作一证总目用承气汤又将脉弦者生涩者死本剧者断语移而继于微者服药之后岂有但
发热谵语无别恶候遽然脉涩而致于死耶仲景论中虽别有潮热谵语脉涩难治一证乃是服承气汤后未曾得大便蕴毒不泄脉
反微涩为正衰邪胜故难治此论中病微者服汤得利后则邪热因泄而解矣尚何生死之议耶又云弦者阳也涩者阴也肠病见阴
脉者生在仲景法中弦涩者属阴不属阳得无疑乎）
许 有人病伤寒大便不利日晡发潮热手循衣缝两手撮空直视喘急更数医矣见之皆走此诚恶候得之者十中九死仲景
虽有证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也与小承气汤一服而大便利
诸疾渐退脉且微弦半月愈或问曰下之而脉弦者生此何意也予曰金匮玉函云循衣妄撮怵惕不安微喘直视脉弦者生涩者死
微者但发热谵语者承气汤主之予尝观钱仲阳小儿直诀云手寻衣领及捻物者肝热也此证在玉函列于阳明部盖阳明者胃也
肝有热邪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医书以发明其隐奥吾
未之见也（海藏云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）
附
娄 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
循衣摸床是病情危重、预后不良的征象，主要有两种证型。其一由太阳中风（风邪侵袭太阳经）用火法强行发汗，导致变证，出现捻衣摸床的症状；若小便通畅者生，小便不利者死。其二由阳明里热极盛所致。
循衣摸床若脉象弦长者则生，脉象涩滞者死。
太阳中风用火法发汗，外感风邪与火热之邪两阳相熏蒸，身体发黄；阳气盛则想流鼻血，阴液虚则小便困难，仅头部出汗，肛门干燥，咽喉溃烂，或者大便不通；日久则出现谵语，严重的甚至呃逆，手足躁动不安，捻衣摸床；若小便通畅者可治（详见头汗条）。伤寒病若经过吐法或下法治疗后病仍未解，大便不通五六天乃至十余天，傍晚时分发作潮热，不恶寒，独自说话如同看见鬼怪一样；如果病情严重，发作时不认识人，循衣摸床，惊恐不安，轻微气喘，两眼直视，脉象弦长的可治，脉象涩滞的不可治。病情较轻的，只是发热、谵语的，用大承气汤主治。如果服一次药后大便通利，就停止后面的服药。（成无己注：若用吐法或下法都会损伤胃气，大便不通五六天乃至十余天，是因为津液枯竭，胃气虚弱，邪热内结。阳明经气旺于申、酉、戌三个时辰，傍晚发作潮热，说明阳明热盛。不恶寒说明表证已罢。独自说话如同见鬼，是阳明腑实内结的表现。认为这是热气有余，如果病情剧烈，则是热气太甚，热邪在体内过盛，扰乱正气神志，使人不识人。至于循衣摸床、惊恐不安、微喘、直视，是伤寒阳胜而阴绝的死证，阴胜而阳绝也是死证。热势剧烈属于阳胜，脉弦表示阴气尚有余存，脉涩表示阴气不足。虽然阳热剧烈，但脉弦说明阴气未绝，还有生机；脉涩则说明阴气已绝，所以无法治疗。如果邪热轻微而未到剧烈的程度，只是发热、谵语，可以用大承气汤来泻除胃中的热邪。经文说：凡是服用泻下药，中病即止，不必服完全部剂量。这里因为热势不剧烈，所以说如果服一次药后大便通利，就停止后面的服药。）
赵嗣真按：这段文字应当分为三部分来看。从“伤寒若吐若下后不解”到“独语如见鬼状”，作为第一部分，是将潮热、谵语、不恶寒、不大便作为现有的证候。下文又分为两部分，以辨别病情轻重之别。“微者”二字为关键义理，指除了发热、谵语之外没有其他证候，使用承气汤每日一服，得利后停服后面剩余的，说明热势较轻，还担心攻下太过。至于“剧者”，发作时不认识人，循衣摸床，惊恐不安，微喘直视，如此热极证危，必须果断判断其死生。依据脉弦者生、脉涩者死，这是因为阳热已极，若脉弦说明阴气未绝，还可以用下法来恢复阴气；若脉涩说明阴气已绝，不可用药，必死无疑。《活人书》只提到“剧者”，而去掉了“微者”二字，将两个证候混为一谈，总纲都用承气汤，又将原本针对“剧者”断语“脉弦者生，脉涩者死”移到了“微者”服药之后。难道仅仅发热、谵语而没有其他恶候，就会突然脉涩而死吗？仲景论中虽然有潮热、谵语、脉涩难治的证候，那是服用承气汤后未曾得大便，蕴毒不泄，脉反微涩，是正气衰败、邪气胜出的缘故，所以难治。此论中“微者”服药得利后，邪热因排泄而解除，哪里还有什么生死议论呢？又说“弦者为阳，涩者为阴”，肠病见到阴脉者生，但在仲景法中，弦涩属阴不属阳，对此怎能不怀疑呢？）
许叔微记载：有人患伤寒，大便不通利，傍晚发作潮热，手循衣缝，两手撮空，两眼直视，气喘急促，多次就医，见到的医生都逃走了。这确实是恶候，得此证者十有九死。仲景虽有此证却无具体方药，只说脉弦者生，脉涩者死。既然已经经过吐下，难以再用峻下药，暂且救急吧。如果大便得通且脉象弦长，或许可以治愈。给予小承气汤，服一次后大便通利，各种疾病逐渐消退，脉象微微带弦，半个月痊愈。有人问：为什么下法之后脉弦者生？这是什么意思？我回答说：《金匮玉函经》云：循衣妄撮，怵惕不安，微喘直视，脉弦者生，脉涩者死。病情轻的，只是发热、谵语的，用承气汤主治。我曾观察钱乙《小儿直诀》云：手寻衣领及捻物者，是肝热。此证在《玉函经》中列于阳明部，盖阳明即胃。肝有热邪淫溢于胃经，故用承气汤泻之。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。读仲景论述而不能博通诸家医书以发明其中的隐奥，我是没见过的。（海藏云：许学士作循衣撮空，认为是肝热风淫末疾，此论确实恰当。不如认为是肺热之邪，其人必然妄言乱语。《难经》云：肺邪入心为谵语。）
附案
娄全善曾治疗循衣摸床数人，都用大补气血的药剂，唯有一人兼有肢体震颤、脉象代止，于是于补剂中略加桂枝二分，震颤即止，脉象调和而痊愈。
The symptom of "grasping at clothes and bedclothes" (Xun Yi Mo Chuang) is a critical sign indicating a poor prognosis. There are two main patterns:
First, it arises from Taiyang Wind Strike (Taiyang Zhong Feng, a syndrome caused by wind pathogen invading the Taiyang channel) where fire therapy was used to forcibly induce sweating, resulting in a complicated disease (Huai Bing). The patient exhibits grasping at clothes and bedclothes; if urination is free, there is hope for survival; if urination is difficult, death ensues. Second, it results from extreme excess heat in the Yangming interior.
If the pulse is wiry (Xian), survival is possible; if the pulse is choppy (Se), death ensues.
In Taiyang Wind Strike, when fire therapy is used to induce sweating, the external wind pathogen and the internal fire pathogen interact like two yangs fanning each other, causing jaundice. When yang is excessive, epistaxis may occur; when yin fluid is deficient, dysuria occurs. There may be sweat only on the head, dryness of the anus, ulceration of the throat, or constipation. Prolonged heat leads to delirium (Chan Yu); in severe cases, hiccups (Yue) occur, with restlessness of the hands and feet, and grasping at clothes and bedclothes. If urination is free, the condition is treatable (see Head Sweat entry).
In Cold Damage (Shang Han), if vomiting or purging therapies were used but the disease persists, with constipation lasting five to six days up to ten or more days, tidal fever (Chao Re) occurs in the late afternoon (Shen, You, Xu hours). There is aversion to cold absent, and the patient speaks alone as if seeing ghosts. In severe cases, the patient loses recognition of others, exhibits grasping at clothes and bedclothes, fearfulness and restlessness, slight asthma (Wei Chuan), and fixed gaze (Zhi Shi). If the pulse is wiry, the patient may survive; if the pulse is choppy, the patient will die. In milder cases, presenting only with fever and delirium, Da Cheng Qi Tang (Great Order the Qi Decoction) is indicated. If bowel movement is achieved after one dose, subsequent doses should be stopped.
(Cheng Wuji's commentary: Vomiting and purging both damage Stomach Qi. Constipation persisting for five to six days to over ten days indicates exhaustion of body fluids and deficiency of Stomach Qi, with evil heat knotting internally. Yangming qi prospers during Shen, You, and Xu hours; tidal fever indicates intense Yangming heat. Absence of aversion to cold signifies that the exterior syndrome has resolved. Speaking alone as if seeing ghosts indicates interior fullness of Yangming. This is attributed to excess heat. If the condition is severe, it is due to extreme heat disturbing the righteous qi, causing confusion and loss of recognition. Grasping at clothes, restlessness, slight asthma, and fixed gaze represent Yang excess leading to Yin exhaustion (death), or Yin excess leading to Yang exhaustion (death). Intense heat indicates Yang excess. A wiry pulse suggests residual Yin, implying potential for life; a choppy pulse indicates Yin exhaustion, making treatment futile. If the evil heat is mild and not yet severe, presenting only with fever and delirium, Da Cheng Qi Tang can be used to purge stomach heat. As the classics state: when using purgatives, stop once the disease is addressed; do not necessarily complete the full dose. Here, since the heat is not severe, it is stated that if one dose results in bowel movement, subsequent doses should be stopped.)
Zhao Sizhen's annotation: This passage should be divided into three parts. From "Cold Damage after vomiting/purging... speaking alone as if seeing ghosts" constitutes the first part, listing tidal fever, delirium, absence of aversion to cold, and constipation as current symptoms. The text then divides further to distinguish between severe and mild cases. The character "mild" (Wei) is key: it refers to cases with only fever and delirium and no other symptoms. Using Cheng Qi Tang once daily, stopping after bowel movement, indicates light heat, cautioning against excessive purging. For "severe" cases, characterized by loss of recognition, grasping at clothes, restlessness, slight asthma, and fixed gaze, the heat is extreme and the condition critical, requiring decisive judgment of life or death based on the pulse: wiry indicates life (Yin not exhausted, allowing purging to restore Yin), choppy indicates death (Yin exhausted, untreatable). *Ren Shu* mentions only "severe" cases, omitting "mild," conflating them under one protocol using Cheng Qi Tang, and placing the "wiry/life, choppy/death" prognosis after the mild case treatment. It is illogical to suggest that mere fever and delirium without other adverse signs would suddenly lead to a choppy pulse and death. Although Zhang Zhongjing mentions another case of tidal fever, delirium, and choppy pulse being difficult to treat, this refers to patients who have taken Cheng Qi Tang but still have no bowel movement, with toxins retained and pulse becoming faint/choppy due to righteous qi decline and evil excess. In the current context, "mild" cases recover after taking the decoction because evil heat is expelled. Furthermore, while some say "wiry is Yang, choppy is Yin," and intestinal diseases showing Yin pulses live, in Zhang Zhongjing's method, wiry and choppy belong to Yin, not Yang, raising doubts.
Xu Shimicro recorded: A patient with Cold Damage had constipation, tidal fever in the late afternoon, grasping at clothing seams, empty hand movements (Cuo Kong), fixed gaze, and rapid breathing. Multiple physicians fled upon seeing these dire signs. This is indeed a malignant sign, with nine out of ten deaths. Zhang Zhongjing described the signs but provided no specific formula, stating only that wiry pulse indicates life and choppy indicates death. Since the patient had already undergone vomiting and purging, harsh purgatives are contraindicated; emergency rescue is needed. If stool passes and the pulse becomes wiry, treatment may succeed. Xiao Cheng Qi Tang (Minor Order the Qi Decoction) was administered. After one dose, stool passed, symptoms subsided, and the pulse became slightly wiry. Recovery occurred in half a month. Question: Why does a wiry pulse after purging indicate life? Answer: *Jin Gui Yu Han Jing* states: Grasping at clothes, fearfulness, slight asthma, fixed gaze; wiry pulse indicates life, choppy indicates death. Mild cases with only fever and delirium are treated with Cheng Qi Tang. I observed Qian Yi's *Xiao Er Zhi Jue*: Hand seeking clothing collars and picking at objects indicates Liver Heat. This syndrome is listed in the Yangming section of *Yu Han*, as Yangming corresponds to the Stomach. Liver heat invading the Stomach channel requires purging via Cheng Qi Tang. A wiry pulse indicates the Liver is pacified and no longer overacting on the Stomach, which is the principle of survival. One cannot understand Zhang Zhongjing without consulting other medical texts to elucidate hidden meanings. (Hanghai noted: Xu Shimicro attributed grasping at clothes to Liver wind-heat affecting the extremities, which is reasonable. Alternatively, it could be Lung heat causing delirium, as *Nan Jing* states Lung pathogen entering Heart causes delirium.)
Appendix Case:
Lou Quanshan treated several patients with grasping at clothes and bedclothes using major tonifying formulas for Qi and Blood deficiency. One patient additionally exhibited tremors and an intermittent pulse (Dai Mai). Lou added a small amount of Guizhi (Cinnamon Twig) to the tonifying formula. The tremors ceased, the pulse became harmonious, and the patient recovered.