High Fever, Talking Nonsense, Grasping at the Air? What to Do When a Sick Person Starts Picking at His Clothes and Grabbing at Nothing — Song Dynasty Master Xu Shuwei Cures Typhoid Delirium and Carphologia With One Dose of Xiao Cheng Qi Tang
Patient search words: fever with delirium / talking nonsense / raving / hands grasping at the air / groping the edge of the bed / fever at the same time every afternoon / constipated / clouded consciousness
Corresponding medical terms: delirium (zhan yu) · feeling along the clothes and bed (xun yi mo chuang) · grasping at the air and threading imaginary lines (cuo kong li xian) · excess pattern of the yang ming bowels (yang ming fu shi) · the most sinister pattern of typhoid
The opening: a patient grasping at the air — and three doctors all backed away
Today we continue the stories of Doctor Xu Shuwei, the great formula master of the Song dynasty. Doctor Xu Shuwei lived through the transition between the Northern and Southern Song dynasties. Also known by his courtesy name Zhike and honored as “Scholar Xu” (Xu Xueshi), he devoted himself to studying Zhang Zhongjing’s Shang Han Lun (Treatise on Cold Damage), excelled at the classical formulas, and wrote Discussion of Ninety Cases of Cold Damage (Shang Han Jiu Shi Lun) — the earliest surviving case-record monograph in Chinese medical history. One case, one discussion: he faithfully recorded the illnesses he had personally treated, one by one.
Today’s case is the eighty-sixth syndrome in that book, and it opens with the most terrifying scene in the whole record: the patient lies in bed, eyes closed, unconscious — one trembling hand pinches the edge of his clothes, while the other hand grasps at the empty air — as if trying to seize something, though there is nothing there at all.
💬 Note from Doctor Luo: If you have ever seen a critically ill patient, you know how frightening this sight is. When a person is near the end, this is often exactly how he looks: eyes closed, hand unconsciously pinching at the seam of his clothes and groping along the edge of the bed, trembling; or both hands reaching into the air again and again, grabbing and twisting at nothing. In Chinese medicine this is called xun yi mi feng, liang shou cuo kong — “the hand seeking the clothes-seam, both hands grasping at the air.” It is a sign that the illness is critical and the mind-spirit has already scattered (xin shen san luan) — in today’s terms, the brain and its nerves are already affected. How precisely the ancients observed this! How carefully they watched!
Who was the patient? Mr. Zhang: 40 years old, typhoid — and first, the bowels stopped
The patient’s surname was Zhang; he was about 40 years old, and he had contracted shang han — cold damage, that is, an externally contracted illness. The earliest symptom was da bian bu li: his stool would not pass freely. Then every afternoon, like clockwork, he ran a fever — ri bu chao re, a daily late-afternoon tidal fever.
💬 Note from Doctor Luo: What time is ri bu? From 3 to 5 p.m. and a little beyond — the shen hour (shen shi). Fever arriving at the same time every afternoon gives the illness a striking time-rhythm — and this is a hallmark sign of yang ming disease. You will understand why in a moment.
Fever and constipation — by themselves, not yet enough to frighten a doctor away. But then the illness turned sharply for the worse: the hand seeking the clothes-seam appeared, both hands grasping at the air appeared, and mu zhi shi — staring eyes — appeared as well.
💬 Note from Doctor Luo: These three are all danger signals. The hand stroking the edge of the clothes, the hands grasping at the air — that is the mind-spirit scattering. Mu zhi shi means the eyes stare straight ahead as if seeing something — in truth the patient cannot see anything clearly anymore; even the optic nerves are affected. At this point, a person has reached a very dangerous pass.
Three doctors in a row: “a malignant typhoid state — it cannot be treated”
Mr. Zhang’s family had already changed doctors three times — the “three” may be a round number; in any case, they had called in several physicians.
💬 Note from Doctor Luo: Each doctor arrived, took one look, and pronounced the same verdict: this is a malignant state of typhoid and cannot be treated (shang han e zheng, bu ke zhi) — the most vicious presentation of an externally contracted illness; the man is finished, nothing can be done.
Just as the family had run out of options, someone thought of Doctor Xu Shuwei.
Doctor Xu Shuwei: “This is truly a vicious sign — nine or ten will die” — but he went anyway
Doctor Xu Shuwei understood perfectly well: a patient already at the stage of “hand seeking the clothes-seam, both hands grasping at the air, staring eyes” was in dire straits. But he was a man of deep benevolence (zhai xin ren hou) — he said: I will go anyway, gritting my teeth and steeling myself. The pattern is truly vicious, but let me at least try.
After examining the patient, Doctor Xu said: “Ci cheng e hou” — this is truly a vicious sign. At this stage, “shi zhong jiu si” — of ten patients, nine will die.
He quoted Zhang Zhongjing: Zhang Zhongjing “sui you zheng er wu zhi fa” — described the pattern but left no treatment method — he only said: “Mai xian zhe sheng, se zhe si” — those with a wiry pulse will live; those with a rough pulse will die. If the pulse still has strength, the person may survive; if the pulse has lost its force and flows like a thin, feeble trickle, then it is over.
What made it worse: this patient had already been through vomiting and purging (tu, xia) — earlier doctors had used emetics and purgatives — so his upright qi (zheng qi) was already wounded. When the upright qi is wounded, the medicine becomes very hard to manage.
💬 Note from Doctor Luo: Doctor Xu said, I will reluctantly write out a formula and try — “mian yi yao er”: if the stool can be moved, and once it moves the pulse is still strong and forceful, then “shang ke liao li” — “there is still something to work with,” still a chance to treat him. If the stool will not move, then truly there is nothing more to be done.
“Shang ke liao li”: the word “ryori” — Japanese cuisine’s name — actually comes from Chinese medicine
Here Doctor Xu used a word — liao li (料理).
💬 Note from Doctor Luo: Isn’t that interesting? In the Song dynasty, looking after and regulating the body was already called “liao li.” Do you know why Japanese cuisine is called “ryori” in Japanese? Japanese scholars have verified it: when the methods of ancient Chinese medicine spread to Japan, the work of attending a sick person — bringing the medicine, pouring the water, using a bit of ginger and jujube to regulate the body — that whole occupation was called “ryori.” Later the kitchen also used ginger and jujube, and gradually the word came to mean cooking; today all Japanese food is called “ryori.” The word comes from Chinese medical practice — this is the Japanese scholars’ own finding, and I find it fascinating. So when Doctor Xu says “shang ke liao li,” he means “it can be attended to, it can still be managed.”
The formula: Xiao Cheng Qi Tang — far gentler than Da Cheng Qi Tang
Which formula did Doctor Xu use? Xiao Cheng Qi Tang (Minor Purgative Decoction).
💬 Note from Doctor Luo: Xiao Cheng Qi Tang is weaker than Da Cheng Qi Tang (Major Purgative Decoction) — it contains no mang xiao (mirabilite), only three ingredients: da huang (rhubarb), hou po (magnolia bark), and zhi shi (immature bitter orange), in smaller doses as well. Doctor Xu was being extremely cautious here: the patient’s upright qi was already wounded, so he dared not use a ferocious purge — only a gentle downward movement, testing the road first.
And the result? One dose, and the stool moved (yi fu er da bian tong)! Just one serving, and the bowels passed! Once the stool moved, zhu zheng jian tui — the alarming symptoms receded one by one. When he felt the pulse again, the pulse was wiry (mai qie xian) — still forceful! Doctor Xu knew he had a foundation to work with. After another half a month of adjustment, the patient was completely well.
💬 Note from Doctor Luo: That single dose turned the whole situation around. Doctor Xu snatched this man back from the brink — truly remarkable. And you will ask: Zhang Zhongjing said “after purging, a wiry pulse means life” — why does a wiry pulse after purging mean the patient can live?
What did Zhang Zhongjing say? “A wiry pulse means life; a rough pulse means death”
Doctor Xu quoted Zhang Zhongjing’s original text and explained the whole principle. Zhang Zhongjing wrote: “In cold damage, if vomiting or purging has been used (ruo tu ruo xia hou)” — someone was vomited, someone was purged, and the illness was not resolved — “da bian bu jian wu liu ri, shang zhi shi yu ri” — no bowel movement for five or six days, even up to ten or more days; “ri bu suo fa chao re” — a tidal fever every afternoon; “bu e han” — no aversion to cold; “du yu ru jian gui zhuang” — talking to oneself as if seeing ghosts.
💬 Note from Doctor Luo: Zhang Zhongjing described this in extraordinary detail. Why does the patient rave and seem to see ghosts? Because the intestines are blocked — yang ming fu shi: waste products are trapped inside, heat and blood are locked in with them, struggling together and generating toxins. Those toxins enter the body — and as we understand today, they genuinely disturb the brain and nerves and enter the blood to unsettle the mind-spirit. The ancients said “rao luan xin shen — disturbing the mind-spirit”; in fact, they were describing interference with the brain’s nerves. A person in this state raves — we call it zhan yu (delirium) — and he truly has hallucinations. If you have ever seen such a patient: talking nonsense, as if he saw ghosts.
Zhang Zhongjing continues: “Ruo ju zhe, fa ze bu shi ren” — in severe cases, when an episode strikes, the patient no longer recognizes people; consciousness sinks; “xun yi mo chuang” — the hand strokes the clothes and gropes along the bed; “ti er bu an” — restless and agitated in the heart; “wei chuan zhi shi” — slight panting and staring eyes.
💬 Note from Doctor Luo: My father in his later years had Parkinson’s disease, and in the final stage he showed exactly this: his hand would stroke the edge of his clothes, grope along the bed, trembling and creeping forward little by little — precisely the xun yi mo chuang of the ancients. In ancient times that was a critical illness; such a patient generally had only days to live. But I kept regulating him with Chinese medicine, and it sustained my father for many years. So Zhang Zhongjing’s “wiry pulse means life, rough pulse means death”: at this point, the patient whose pulse still has force may live; the one whose pulse has already grown weak is in danger.
Did Zhang Zhongjing give a treatment? He distinguished mild from severe. For the milder forms — fever and raving — he said Da Cheng Qi Tang (Major Purgative Decoction) governs, with the instruction “ruo yi fu li, ze zhi hou fu”: once one dose has brought the bowels open, stop taking it — the heat pathogen and toxins that were disturbing the mind have been purged out, and that is enough. But for the severe forms — feeling along the clothes and bed, failing to recognize people — Zhang Zhongjing did not say how to treat them; he left only the line “wiry pulse means life, rough pulse means death.”
Doctor Xu Shuwei was puzzled too: what does one do about the severe form?
One sentence from Qian Yi — and the whole case clicked open
At this point, Doctor Xu remembered a remarkable predecessor — Qian Yi (Qian Zhongyang).
💬 Note from Doctor Luo: Doctor Xu said: I once read Qian Yi’s Xiao Er Yao Zheng Zhi Jue (Key to the Syndromes of Children’s Diseases), which contains this line — “Shou xun yi ling ji luan nian wu zhe, gan re ye”: a hand that seeks the collar of the clothes and randomly twists objects is liver heat. What does it mean? When the mind-spirit is disordered, the hands tremble, cannot hold things steady, and whatever is picked up gets twisted and kneaded as if being rolled. Qian Yi gave this phenomenon a diagnosis: it is liver heat, of the liver-wind kind. See how remarkable Qian Yi was — he even influenced Doctor Xu Shuwei.
The insight struck Doctor Xu like a door opening: this illness is listed under the yang ming chapter of the Shang Han Lun, and yang ming is the stomach. So if the liver harbors pathogenic heat, and that heat invades the stomach channel — that is why the Cheng Qi decoction is used to purge: on one side it drains yang ming fire (the heat in the stomach), and on the other it drains the liver. And if, after the purge, the pulse is still strong and forceful, what does that prove? It proves that the stomach qi is still solid (wei qi jian shi) — the stomach is solid, the pulse is strong, level, and harmonious; the pathogen cannot invade it. At that point the patient may live — there is a real chance of rescue.
💬 Note from Doctor Luo: So Doctor Xu used Xiao Cheng Qi Tang: this patient’s upright qi was still somewhat deficient, so a gentle purge with the Minor Purgative Decoction was enough — expel whatever was obstructing the qi mechanism, and once it is expelled, the body’s own upright qi recovers by itself; with the upright qi sufficient, the person lives. That is the meaning of “after purging, a wiry pulse means life” — the stomach qi is still there; the foundation is still there.
How a formula master studies: you cannot read Zhang Zhongjing’s books in a dead letter
The key to this case is a reflection Doctor Xu left behind. He said: I have always said — with Zhang Zhongjing’s books, you cannot only read Zhongjing’s books. If you read only Zhongjing’s works, your thinking never opens up; you must read the books of all the schools (zhu jia), using other physicians’ works to inspire your thinking, and thereby expound (chan fa) the hidden, unwritten parts of Zhang Zhongjing’s teaching. Not to do so is not enough — with only Zhongjing’s books, there are things you will never grasp.
💬 Note from Doctor Luo: Doctor Xu’s own words were “Xu yi gu jin fang shu, fa ming Zhongjing yu yi” — you must not read Zhang Zhongjing’s books in a dead letter; read the medical books ancient and modern, fuse them into one understanding, and from that fusion expound and realize the principles Zhongjing taught. This passage is extremely important: it shows how this great formula master actually studied the Shang Han Lun — not, as we might imagine, simply memorizing Zhongjing’s text. No. He read everyone’s books: Qian Yi’s books, Sun Simiao’s (Master Sun’s) books, and many more. That is why Discussion of Ninety Cases of Cold Damage contains many cases treated by later methods. Doctor Xu’s self-study was extraordinarily rigorous: he read the books of every dynasty and generation, and only then entered into the principles of Zhongjing — that is how he saw so broadly. This is a study method, and I pass it on to you.
Bonus, part one: why purge yang ming fu shi? First, a word about the gut microbiome
Using this case as a springboard, Doctor Luo explains the reasoning behind the Chinese medical “purging method” in modern terms, broken down piece by piece:
First: Chinese medicine has always been clearing whatever obstructs the movement of qi and blood. Doctor Luo has said before: anything that obstructs the body’s qi-mechanism and blood circulation pushes the body into a diseased state — especially when an external pathogen is present: the pathogen attacks, and the body must mobilize energy to resist it; if something blocks the movement of qi and blood, the resistance is weakened and the illness worsens. So Chinese medicine has always worked to clear these obstructions: there are methods to resolve blood stasis (hua yu xue), and formulas that purge downward (xie xia); when qi and blood congeal, we have warming formulas; when there is heat, we have descending formulas — for example, Bai Hu Tang (White Tiger Decoction) — to bring a raging fever down.
Second: the bacteria in the gut weigh one to two kilograms — heavier than many organs. Do not underestimate the intestines: they harbor enormous numbers of microbes — so many that the flora can be regarded as an organ of the body. A person with normal flora may host eight or nine hundred to about a thousand species; someone living in the mountains, eating healthily, may have a thousand to twelve hundred; a city dweller whose diet is a mess and who has taken antibiotics may have only five or six hundred.
💬 Note from Doctor Luo: Among these microbes are beneficial bacteria — they help us break down food and transport nutrients to the whole body, which partly overlaps with the Chinese medical concept of the spleen (pi); there are harmful bacteria — normally kept under excellent control, doing no harm within a certain range; and neutral bacteria — neither good nor bad. A healthy person’s flora should weigh 1 to 2 kilograms — see that weight, heavier than many organs. Some of these bacteria are extremely important: they are part of the immune system, performing immune functions. So the intestine is also a major immune organ of the body, and it is connected to our consciousness, to personality, emotions, metabolic state, and immune strength.
Third: why does Chinese medicine always talk about tonifying the spleen-earth (bu pi tu)? Tonifying the spleen-earth so that upright qi is abundant and stomach qi is strong — this is actually tied to the survival of the beneficial bacteria. Chinese yam (shan yao), lotus seed (lian zi), and similar foods are what the beneficial bacteria love to eat — they are the bacteria’s “culture medium”; and in formulas that clear damp-heat, the huang lian (coptis) and huang bai (phellodendron) are there to kill the harmful bacteria — the ancients’ regulation was targeted. There are so many spleen-tonifying formulas because the ancients understood this clearly.
Bonus, part two: when the gut flora collapses, the person is in danger too
So what happens during illness? The gut flora become disordered: harmful bacteria proliferate (because the immune system is failing), beneficial bacteria decline, the bowels become blocked, and the blockage makes the flora even more disordered — a vicious cycle. Add a high fever: body fluids run low, the environment for the gut flora changes, the stool is even harder to pass, and the flora shift further. At this point, some harmful bacteria migrate upward, crossing the intestinal barrier into the body — and if they irritate the nervous system, we see what we call shen hun zhan yu — clouded consciousness and delirium, even the xun yi mo chuang and cuo kong li xian of Zhang Zhongjing. Toxins have entered the body and are worsening the illness.
💬 Note from Doctor Luo: So when the gut flora collapse — when this system completely breaks down — the collapse of the person is not far behind. The ancient Chinese doctors were remarkably clever. What did they do? Purge quickly: empty the intestinal environment and let the flora restart — reboot the whole system. In the cecum of the intestine there are places that preserve “seeds” of the flora; some bacteria are stored there, like a Noah’s ark, with the function of regenerating and restarting the bacterial system. Purge it out, empty it, change the unfavorable situation in the intestines, and let the flora regenerate. You see, whenever a person reaches yang ming fu shi, the situation is dangerous — and Chinese medicine often uses Da Cheng Qi Tang or Xiao Cheng Qi Tang, one purge, and the patient recovers at once. The ancient doctors actually grasped how to adjust the gut flora and the immune system, preventing toxins from entering the body and causing greater disaster. That is truly remarkable.
But don’t oversimplify yang ming fu shi. After using the Cheng Qi decoctions, the experience of later generations says: slowly tonify the spleen — help the beneficial bacteria recover their numbers quickly: eat Chinese yam, regulate the stomach and spleen, take a little Bu Zhong Yi Qi Tang (Tonify the Middle and Augment the Qi Decoction) or Liu Jun Zi (Six Gentlemen) pills, together with yam and lotus seed — and the aftercare recovery will be very solid.
💬 Note from Doctor Luo: If you think of it simply — yang ming fu shi just means waste trapped in the bowels; purge it out, the stool moves, and you’re done — then you have understood it too shallowly. If it were that simple, almost every constipated person would be in critical condition. In reality yang ming fu shi is not the same as ordinary constipation: ordinary constipation does not necessarily trigger such a massive disturbance of the flora — maybe a slight disturbance; but the yang ming fu shi pattern is one in which the intestinal flora are already severely disordered, already in a state of collapse — which is why it produces such grave consequences. The Cheng Qi decoctions are a rescue method here: quickly empty the bowels so that no more toxins and toxic blood enter the body, lighten the body’s burden, and let it recover on its own.
Closing: protecting the inner environment of the gut is protecting life itself
At this point Doctor Luo brings the discussion back to everyday life: protecting the stability of the gut’s inner environment is extremely important.
💬 Note from Doctor Luo: How? In food: more whole grains, more normal eating, and less junk — additives and preservatives kill off various flora; preservatives certainly kill microbes. Use antibiotics sparingly — don’t casually massacre your flora. The same applies to children: as the flora dwindle, the body weakens — and a weak body is exactly what we call spleen deficiency (pi xu). So everyone should protect their gut flora. If you look at ancient Chinese medical treatment from this angle, you will see it far more clearly — the ancients did not know how many species of bacteria there were, but this is precisely the angle from which they handled the problem, and their handling matches today’s research findings remarkably well. The ancients truly were extraordinary.
And Doctor Luo ends with a reflection: our lives go well, to a very large degree, because of that one or two kilograms of flora inside us. Most of them are our good friends, helping us move qi and blood and keep everything flowing. We are a community with them — and on the largest scale, this is what is called tian ren he yi — the unity of heaven and humanity; we and nature are one. Understand life this way, and we will gain much deeper insight into life itself.
Compiled from Doctor Luo Dalun’s commentary on Doctor Xu Shuwei’s case records; the case is from Discussion of Ninety Cases of Cold Damage (《伤寒九十论》, Southern Song dynasty, by Doctor Xu Shuwei).