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Delirious speech (Zhanyu) refers to the symptom of speaking wildly and incoherently due to clouded consciousness. When heat in the Yangming channel reaches its extreme, it ascends to invade the Heart and Lungs, causing confusion of the spirit. In mild cases, there is muttering during sleep; in severe cases, incoherent speech occurs even when awake.

The Classics state: Delirious speech, solitary muttering, incessant talking, as well as manic and chaotic speech, are named according to the severity of the disease. Here, eight types of delirious speech are distinguished: exterior-heat delirium, heart-heat delirium, stomach-heat delirium, lung-heat delirium, food-stagnation delirium, dry-feces delirium, phlegm-heat delirium, and blood-stasis delirium.

1. Exterior-heat delirium: Although the body has high fever, only the feet are cold. This may be due to concealed sha-toxin or rheumatism-wind binding, causing whole-body pain. Since the pathogen cannot vent from the exterior, it attacks inward, causing delirium. If the disease is in the Taiyang channel, use Qianghuo Tang; if in the Yangming channel, use Shengma Gegen Tang; if in the Shaoyang channel, use Chaihu Tang.

2. Heart-heat delirium: Movement triggers manic fright; stillness brings self-laughter. The tongue coating is black with prickles, and the patient is often drowsy without a moment of clarity. The left Cun pulse is rapid. Use Daochi Geban Tang.

3. Stomach-heat delirium: The patient alternates between mania and clarity. Lips are cracked and parched, with a yellow tongue coating and a rapid Right Guan pulse. Use Qingwei Tang or Sanhuang Jusheng Tang. If hands and feet sweat profusely, indicating unresolved exterior pathogen but urgent interior excess, choose Daxiehu Tang or Da Gan Ge Tang.

4. Lung-heat delirium: The Lung stores the Po (corporeal soul). Fire injury to the Lung disturbs the Po, causing occasional weeping or coughing/sneezing. Treat primarily with Liangge San.

5. Food-stagnation delirium: External wind-cold combined with internal dietary injury causes pathogenic factors and food stagnation to bind together, triggering delirium. Distinctive features include non-cracked lips, non-dry tongue, and thirst without desire to drink water, distinguishing it from interior-heat delirium. Treatment should use Baohe San, with doubled doses of Zhishi, Shichangpu, Shanzha, and Laifuzi. At the onset, induce vomiting first, followed by digestive herbs. Premature use of cold/cool herbs causes stagnation and worsens delirium. Premature purgation leads to chest binding (Jie Xiong syndrome). Even if constipation and abdominal fullness indicate a need for purgation, only Mangxiao and Xuanmingfen should be used to dissolve hardness without causing stagnation. Avoid heavy, cloying purgatives like Dahuang.

6. Dry-feces delirium: Heat pathogens reside in the chest, while dry feces accumulate in the abdomen. Heat binds internally, unable to descend, and steams upward to disturb the Heart and Lungs. Symptoms include cracked lips, dry mouth, umbilical/abdominal fullness, constipation, and frequent sweating of hands and feet. This is a delirium requiring purgation. Choose among the Three Chengqi Decoctions.

7. Phlegm-heat delirium: Phlegm-fire in the Heart and Stomach attacks the collateral vessels, disturbing the "Monarch" (Heart spirit), leading to frequent delirium. The mouth is not thirsty, and the tongue has a slippery coating. Cold herbs will worsen delirium; use Daotan Tang. For hard stools, use Zhimi Wan. Wu Shi recommends taking one cup of Bamboo Sap mixed with one cup of juice from fresh crushed Gua Lou Gen, taken warm, to clear phlegm-heat and smooth bowel movements. This differs from silence caused by cold-stagnation and food retention, where cold/moistening herbs are contraindicated.

8. Blood-stasis delirium: Rinsing the mouth with water but being unable to swallow, yellow skin and eyes, and manic speech indicate upper-jiao blood stasis. Lower-jiao blood stasis presents with lower abdominal fullness and patent urination. For upper-jiao, use Xijiao Dihuang Tang plus Honghua and Danggui; for lower-jiao, use Tao Ren Chengqi Tang.

In Yangming disease, delirium accompanied by tidal fever and a slippery, rapid pulse is treated with Xiao Chengqi Tang. Administer one sheng of Chengqi Tang; if flatus occurs, administer another sheng. If no flatus occurs, do not administer more. If the next day there is still no stool and the pulse becomes faint and choppy, it indicates deficiency of interior Qi, which is difficult to treat; do not give Chengqi Tang again. (See notes on Tidal Fever). The following four chapters detail the differentiation of delirium and the application of Chengqi methods.

In Yangming disease, delirium with tidal fever and inability to eat indicates five or six pieces of dry feces in the stomach. If the patient can eat, the stool is merely hard; use Da Chengqi Tang. (See notes on Tidal Fever).

In Yangming disease, excessive sweating depletes fluids, drying the stomach and hardening the stool, leading to delirium. Treat with Xiao Chengqi Tang. If delirium ceases after one dose, do not administer more. (See notes on Spontaneous Sweating).

Sweating with delirium indicates dry feces in the stomach due to Wind. Purging is required, but must wait until the disease has passed into the next stage. Premature purging causes chaotic speech due to exterior deficiency and interior heat. Once the timing is right, purging with Da Chengqi Tang will cure the condition.

The phrase "exterior deficiency and interior heat" located under "must purge" in this chapter has been historically misunderstood. (Refer to notes on Spontaneous Sweating for cross-reference).

Excess conditions manifest as delirious speech; deficiency conditions manifest as Zhengsheng (repetitive speech). Zhengsheng involves repeating the same words due to insufficient upright Qi, whereas excess delirium involves varied, manic speech.

Fixed gaze with delirium, accompanied by wheezing and fullness, indicates death; fixed gaze with delirium accompanied by diarrhea also indicates death. Fixed gaze with delirium is a ominous sign; if wheezing and fullness appear, death is certain. If diarrhea appears, death is also certain.

Excessive sweating or repeated sweating leads to loss of Yang and delirium. A short pulse indicates death; a harmonious pulse indicates survival. Yang-excess delirium involves pathogenic disturbance of the mind-spirit and is treatable; Yang-loss delirium involves the loss of spiritual mastery, so a short pulse indicates death, while a harmonious pulse allows for survival.

In Shanghan (Cold Damage) at day 4 or 5, a deep pulse with wheezing and fullness indicates interior pathology. Counter-productive sweating causes fluid loss, difficulty in defecation, and a complex pattern of exterior/interior excess/deficiency, eventually leading to delirium. A deep pulse indicates interior pathogens; inappropriate sweating depletes fluids, drying the intestines and stomach. Although Zhang Zhongjing did not prescribe a formula here, the text implies gently harmonizing Stomach Qi.

After emetic or purgative treatment for Shanghan, if the disease persists with constipation for 5-6 days up to 10+ days, and tidal fever occurs in the late afternoon (Ribu) without aversion to cold, accompanied by solitary muttering as if seeing ghosts: Severe cases involve unconsciousness, picking at clothes and beds, fearfulness, slight wheezing, and fixed gaze. A string-taut pulse suggests survival; a choppy pulse suggests death. Mild cases with only fever and delirium are treated with Da Chengqi Tang. If one dose produces loose stools, stop administration.

Post-emesis/purgation persistence with constipation, solitary muttering, unconsciousness, picking at clothes/beds, fearfulness, slight wheezing, and fixed gaze: String-taut pulse indicates life; choppy pulse indicates death. If the pulse is faint with only fever and delirium (without ominous signs), Chengqi Tang may be given. If one dose results in free bowel movement, do not continue.

Qianghuo Tang, Shengma Gegen Tang, and Chaihu Tang are referenced in the "Aversion to Cold" section.

Daochi Geban Tang
Chuanlian, Gancao, Shengdi, Mutong, Zhimu, Huashi, Maidong, Shanzhi, Huangqin, Xijiao.
For heart-heat delirium, clear Heart channel heat. The best way to clear Heart heat is to promote urination first.

Qingwei Tang
Chuanlian, Shengma, Shengdi, Shanzhi, Gancao.
Clearing Heart heat is one method for treating delirium. However, for stomach-heat delirium, clearing the Stomach is prioritized. Hence, Daochi Geban Tang is listed first, followed by Qingwei Tang.

Sanhuang Jusheng Tang
Huangqin, Huanglian, Dahuang, Shanzhi, Shigao.
Since heat affects all three Yang channels, Sanhuang Tang clears them simultaneously. Adding Shigao and Shanzhi greatly enhances efficacy.

Da Gan Ge Tang is referenced in the "Headache" section.
For delirium with interior excess, Chengqi Tang is indicated. If Yangming exterior pathogen remains, the author's secret method uses Gan Ge and Shigao with Dahuang and Zhike to resolve both exterior and interior Yangming. This is derived from the Daxiehu Tang method for resolving Shaoyang exterior/interior. Note: Qingwei Tang clears Foot-Yangming Stomach heat; Da Gan Ge Tang clears Hand-Yangming Large Intestine heat.

Liangge San
Jiegeng, Huangqin, Shanzhi, Lianqiao, Xuanshen, Tianhuafen, Bohe, Gancao, Huanglian, Xuanmingfen.
While heart and stomach heat delirium are known, lung-heat delirium is often overlooked. Excessive upper-jiao heat confuses the spirit; thus, Liangge San clears the spirit to treat delirium.

Zhishi Pingwei San
Re Cangzhu, Nongpo, Guangpi, Gancao, Zhishi, Shichangpu, Shanzha Rou, Laifuzi.
Food stagnation in the Stomach, external wind-cold, and cold stagnation suppression all cause delirium. Thus, Pingwei Baohe San is formulated with added Zhishi, Changpu, and Laifuzi.

Daotan Tang
Banxia, Nanxing, Zhishi, Chi Fuling, Juhong, Shichangpu, Gancao, Haishi.
Add Huanglian if heat is present.
For food-stagnation delirium, use Pingwei San for digestion; for phlegm binding in the Middle Jiao, use phlegm-resolving methods.

Zhimi Wan
Banxia, Chenpi, Gancao, Bai Fuling, Zhishi, Xuanmingfen.
For phlegm binding in the Stomach, use Daotan method; for hot-phlegm binding in the Large Intestine, use Zhimi Wan.

Xijiao Dihuang Tang is referenced in "Body Pain" and "Epistaxis" sections.
Manic delirium may also be confirmed blood-stasis; modify this formula accordingly.

Tao Ren Chengqi Tang is referenced in "Blood Stasis" section.

Da Chengqi Tang is referenced in "Constipation" section.