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（手指无意识地抓摸衣物和床沿）是病情危重、预后不良的征象，主要有两种证型。其一是由太阳中风证误用火法劫汗，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；其二是由阳明里热极盛所致。
脉象弦长者生，脉象涩滞者死。
太阳中风证若用火法发汗，邪风与火热两阳相熏蒸，身体发黄；阳气盛则欲流鼻血，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（胡言乱语），严重者甚至呃逆（打嗝不止）、手足躁扰不宁、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，甚至十余天，在日晡时（下午3-5点）发作潮热，不恶寒，独自说话，好像看见鬼怪一样。如果病情严重，发作时不认识人，手循衣缝、摸床沿，惊恐不安，轻微气喘，两眼直视，脉象弦长者生，脉象涩滞者死。病情较轻者，仅表现为发热、谵语，用大承气汤主治。如果服用一次后大便通利，就停止后续服药。（成无己注：无论是吐法还是下法，都会损伤胃气。不大便从五六天到十余天，是因为津液枯竭，胃气虚弱，邪热内结。阳明经气旺于申、酉、戌时，故在日晡时发作潮热，这是阳明热甚的表现。不恶寒说明表证已罢。独自说话如见鬼状，是阳明腑实内结的表现。认为热气有余，若病情剧烈，则是热气太甚，热盛于内，昏蒙正气，导致不识人。至于循衣摸床、惊恐不安、微喘、直视，是伤寒中阳胜而阴绝的死证，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，但脉弦说明阴未绝，还有生机；脉涩则阴绝，不可治疗。若邪热轻微而未至剧烈，仅发热谵语，可用大承气汤来泻除胃中的热邪。经文说：凡是服用下药，中病即止，不必服完全部剂量。这里因为热势未剧，所以说如果服一次后大便通利，就停止后续服药。〔赵嗣真〕这一段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。下文又分为一部分，以辨别病情轻重之殊。“微者”二字为关键义理，指除了发热谵语外没有其他证候，使用承气汤每日一服，得利即止后续服药，说明其热轻，还担心攻下太过。至于“剧者”，发作时不识人，循衣摸床，惊恐不安，微喘直视，如此热极证危，必须果断判断其生死。以脉弦者生、涩者死来断语。此时阳热已极，若脉弦为阴未绝，犹可攻下以恢复阴液；若脉涩为阴绝，不可用药，必死。今《活人书》只说“剧者”，而去掉了“微者”二字，将两个证候混为一谈，总目都用承气汤，又将原本用于判断“剧者”预后的“脉弦者生涩者死”移到了“微者”服药之后。难道仅仅发热谵语、无其他恶候，就会突然脉涩致死吗？仲景论中虽有另外一条关于潮热谵语、脉涩难治的记载，那是服用承气汤后未曾得大便，蕴毒不泄，脉反微涩，为正衰邪胜，所以难治。此段论述的是病情轻微者，服汤得利后，邪热因泄而解，还有什么生死议论呢？又说“弦者为阳，涩者为阴”，肠病见阴脉者生，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，日晡时发作潮热，手循衣缝，两手撮空（空中抓取动作），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，得此证者十人中九人死亡。仲景虽然有此证却无具体方药，只说脉弦者生、涩者死。既然已经经过吐下，难以再用峻下药，暂且救急吧。若大便得通而脉转弦，或许可以治愈。给予小承气汤，服用一次后大便通利，诸疾渐退，脉象微弦，半月痊愈。有人问：为什么攻下后脉弦者生？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，涩者死。病情轻微者仅发热谵语，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。肝有热邪淫于胃经，故用承气汤泻之。且得到弦脉，则肝气平和而不克制胃土，这就是所谓有生之理。读仲景著作不能博通诸医书以发明其隐奥，我是没见过的。（海藏云：许学士作“循衣撮空”是肝热风淫末疾，此论诚然。不如认为是肺热之邪，其人必妄言乱语。《难经》云：肺邪入心为谵语。）
附案
娄全善曾治疗几个出现循衣摸床症状的人，都使用大补气血的药剂。唯有一人兼有肢体震颤、脉代（间歇脉），于是于补剂中略加桂枝二分，震颤即止，脉象调和而愈。
Grasping at clothes and bedrails (involuntary grasping movements) is a critical sign indicating a poor prognosis. There are two main syndromes: one arises from Wind-stroke of the Taiyang stage where fire therapy was mistakenly used to induce sweating, leading to a complicated disease with signs of picking at clothes and bedrails; if urination is free, there is hope for survival, but if difficult, death ensues. The other arises from extreme excess heat in the Yangming interior.
A wiry pulse indicates survival, while a choppy pulse indicates death.
In Wind-stroke of the Taiyang stage, if fire therapy is used to induce sweating, the pathogenic wind and fire combine to scorch the body, causing jaundice. Excess Yang leads to epistaxis; Yin deficiency leads to dysuria, sweating only on the head, dryness of the anus, throat ulceration, or constipation. Prolonged occurrence leads to delirium; severe cases may involve hiccups, restlessness of the hands and feet, and grasping at clothes and bedrails. If urination is free, it is treatable (see "Sweating on the Head").
In Cold Damage, if after emesis or purgation the condition remains unresolved, with constipation persisting for five to six days or even ten-plus days, tidal fever occurs during the Shen-You-Xu hours (3 PM - 7 PM), without aversion to cold, accompanied by muttering as if seeing ghosts. In severe cases, upon onset, the patient does not recognize people, picks at clothes and bedrails, feels terrified and uneasy, has slight panting, and stares fixedly. A wiry pulse indicates survival, while a choppy pulse indicates death. In milder cases, presenting only with fever and delirium, Da Cheng Qi Tang (Major Order the Qi Decoction) is the primary treatment. If bowel movement is achieved after one dose, subsequent doses should be stopped. (Cheng Wuji's commentary: Both emesis and purgation damage Stomach Qi. Constipation lasting from five to ten days results from fluid exhaustion, weak Stomach Qi, and internal binding of pathogenic heat. Yangming Qi prospers during the Shen-You-Xu hours, hence tidal fever occurs then, indicating severe Yangming heat. Absence of aversion to cold signifies the resolution of exterior syndrome. Muttering as if seeing ghosts indicates Yangming interior excess. While heat is considered surplus, severe cases imply excessive heat. Extreme internal heat confuses Zheng Qi, leading to disorientation. Grasping at clothes, terror, slight panting, and fixed staring represent Yang excess and Yin exhaustion (death), or Yin excess and Yang exhaustion (death). Severe heat belongs to Yang excess. A wiry pulse suggests Yin is still present; a choppy pulse suggests Yin deficiency. Although Yang heat is severe, a wiry pulse indicates Yin is not exhausted, allowing for potential recovery. A choppy pulse indicates Yin exhaustion, making treatment impossible. If pathogenic heat is mild and not severe, presenting only with fever and delirium, Da Cheng Qi Tang can be used to purge Stomach heat. The classic states: when using purgatives, stop once the disease is addressed; do not necessarily finish the full dose. Here, because heat is not extreme, it says if one dose achieves bowel movement, stop subsequent doses. [Zhao Sizhen] This passage should be divided into three parts. From "Cold Damage after emesis/purgation" to "muttering as if seeing ghosts" constitutes the first part, listing tidal fever, delirium, no aversion to cold, and constipation as current symptoms. The following text divides further to distinguish between severe and mild cases. The character "mild" 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 and caution against over-purging. For "severe" cases, characterized by disorientation, grasbing, terror, panting, and staring, the heat is extreme and the condition critical, requiring decisive judgment of life or death based on the pulse. Wiry pulse means survival, choppy means death. At this point of extreme Yang heat, a wiry pulse indicates Yin is not exhausted, allowing purgation to restore Yin; a choppy pulse indicates Yin exhaustion, making medication futile. *Ren Shu* omits "mild," conflating the two syndromes under Cheng Qi Tang, and places the prognostic pulse criteria for "severe" cases after the "mild" cases' treatment. Would mere fever and delirium suddenly lead to a choppy pulse and death? Zhang Zhongjing mentions another case of tidal fever, delirium, and choppy pulse being difficult to treat, which applies to patients who took Cheng Qi Tang but had no bowel movement, leading to toxin retention and a choppy pulse due to righteous Qi decline and pathogen excess. In the current discussion, mild cases resolve heat through purgation after taking the medicine, so there is no debate on life or death. It also states "Wiry is Yang, Choppy is Yin." Intestinal diseases showing Yin pulses survive, yet in Zhang's method, wiry/choppy belong to Yin, not Yang, raising doubts.)
Xu Shimiao recorded: A patient with Cold Damage suffered constipation, tidal fever at the Shen-You-Xu hours, picked at clothing seams, made empty-handed grasping movements, stared fixedly, and panted rapidly. Multiple physicians visited and fled, recognizing this as a dire sign with a 90% mortality rate. Zhang Zhongjing described the syndrome but provided no formula, stating only that a wiry pulse indicates survival and a choppy pulse indicates death. Since emesis and purgation had already been used, harsh purgatives were contraindicated. I attempted emergency rescue. If bowel movement occurred and the pulse became wiry, cure might be possible. I administered Xiao Cheng Qi Tang (Minor Order the Qi Decoction). After one dose, bowel movement was achieved, symptoms gradually subsided, and the pulse became slightly wiry. Recovery took half a month. When asked why a wiry pulse after purgation indicates survival, I replied: *Jin Gui Yu Han Jing* states: Grasping at clothes, terror, slight panting, fixed staring, wiry pulse indicates survival, 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* stating: Seeking shirt collars and picking at objects indicates Liver Heat. This syndrome is listed under Yangming in *Yu Han*, as Yangming corresponds to the Stomach. Liver heat invading the Stomach meridian is treated with purgation. Obtaining a wiry pulse indicates Liver equilibrium, preventing it from overacting on the Stomach, which is the rationale for survival. One cannot understand Zhang Zhongjing without consulting other medical texts to elucidate hidden depths. (Hai Zang noted: Xu Shimiao attributed "grasping at clothes" to Liver Wind and Heat. This is plausible. However, it may be Lung Heat causing delirium. *Nan Jing* states: Lung pathogen entering the Heart causes delirium.)
Appendix Case
Lou Quanshan treated several patients exhibiting grasping at clothes and bedrails using major Qi and Blood tonifying formulas. One patient additionally presented with tremors and a intermittent pulse (Dai Mai). Lou added a small amount of Guizhi (Cinnamon Twig) to the tonifying formula. The tremors ceased, the pulse harmonized, and the patient recovered.