Library

(Yangming disease refers to the excess syndrome of the stomach and intestines. When the stomach and intestines are in a state of excess, delirious speech occurs; therefore, delirious speech should be discussed under the chapter of Yangming disease.)

Cheng Wuji: Delirious speech (Shanyu) refers to the patient speaking incoherently while confused; another interpretation is speaking based on hallucinations or false perceptions. These conditions arise because excessive heat in the stomach rises to affect the heart, disturbing the mind and causing confusion of consciousness, leading to disordered speech. In mild cases, the patient mutters in their sleep; in severe cases, they speak incoherently even when awake. The classics mention delirious speech, solitary muttering, manic speech, continuous talking, and nonsensical speech, all resulting from varying degrees of heat pathogen. (Delirious and confused speech, if structured like a conversation or speaking alone as if seeing ghosts, indicates mild heat; manic speech with loss of awareness, shouting, and continuous talking indicates severe heat; nonsensical speech, cursing without distinguishing kin or strangers, indicates that the spirit has been severely disturbed and is difficult to restore to its normal state.)

The causes of delirious speech vary. They may result from fire therapy forcing sweat, excessive sweating, diarrhea, bleeding, dry stool in the stomach, concurrent diseases of three yang meridians, passing through stages without resolution, or loss of yang qi. These situations are detailed later, so they are not repeated here. In such cases, a short pulse indicates a poor prognosis (death), while a harmonious pulse indicates recovery. If the body has slight fever and the pulse is floating and large, survival is possible; if limbs are cold and the pulse is sunken and fine, death may occur within a day. Alternatively, rebellious qi causing wheezing and chest fullness, or downward depletion causing spontaneous diarrhea, are both adverse conditions.

In Yangming stomach excess with tidal fever, purgation is indicated.
In Yangming disease, with delirious speech and tidal fever, and a slippery and rapid pulse, Xiao Chengqi Tang (Minor Order the Yellow Decoction) is the primary formula. Administer one cup of Xiao Chengqi Tang; if flatus occurs in the abdomen, administer another cup. If no flatus occurs, do not continue administration. If there is still no bowel movement the next day and the pulse becomes slightly choppy and forceless, it indicates interior deficiency, which is difficult to treat; do not administer Chengqi formulas again.
In Yangming disease, with delirious speech and tidal fever, but inability to eat, there must be dry stools (five or six pieces) in the stomach. If the patient can eat, the stool is merely hard; Da Chengqi Tang (Major Order the Yellow Decoction) is indicated for purgation.
In concurrent diseases of two yang meridians, after Taiyang symptoms resolve, presenting only with fever, continuous sweating on hands and feet, difficulty in defecation, and delirious speech, purgation leads to cure; Da Chengqi Tang is indicated.
In Yangming disease, if the patient sweats excessively, fluids are lost, leading to dryness in the stomach and hard stools, resulting in delirious speech; Xiao Chengqi Tang is indicated. If delirium stops after one dose, do not administer further.

For stomach excess with profuse sweating, purgation is indicated.
Sweating accompanied by delirious speech indicates dry feces in the stomach due to wind pathogen. Purgation is necessary, but only after the exterior stage has passed (Guojing). Premature purgation leads to disordered speech because the exterior is deficient and the interior is excess; purgation will lead to cure, using Da Chengqi Tang. Excess manifests as delirious speech, while deficiency manifests as Zhengsheng (repetitive weak speech). (Delirious speech involves chaotic words changing frequently; Zhengsheng involves repeating the same phrase repeatedly due to lack of mental energy. Excess spirit allows for varied speech, while deficient spirit lacks variation.)
In Cold Damage after four or five days, with a sunken pulse and wheezing/fullness, sunken indicates interior location. Counteracting this with diaphoresis causes fluid loss, making defecation difficult. Exterior deficiency and interior excess lead to delirious speech over time. (Cheng's view that Zhengsheng refers to Zheng-Wei sounds is incorrect, as clarified previously.)

After Fire Therapy:
Symptoms resemble Cold Damage, but the pulse is weak rather than string-tight. Weak pulse implies thirst; fire therapy will cause delirious speech. If weak pulse accompanies fever and is floating, resolving the exterior with sweating leads to cure.
After fire therapy forcing sweat in Taiyang disease, presenting with yellow skin, difficulty urinating, dry body, head sweating, abdominal fullness, slight wheezing, or constipation, prolonged cases develop delirious speech. (See "Head Sweating" section.)
On the second day of Taiyang disease, irritability appears. Back moxibustion causes profuse sweating, allowing fire heat to enter the stomach, depleting fluids, causing irritability and delirious speech. After ten-plus days, shaking chills and spontaneous diarrhea indicate impending resolution.
In Shaoyin disease, coughing with diarrhea, delirious speech, and difficulty urinating result from fire pathogen forcing sweat. After emesis, purgation, sweating, or warm needle therapy, if delirious speech occurs and Chaihu syndrome resolves, it is a damaged disease; treat according to the deviation. (See Damaged Disease section.)

After Sweating:
Cold Damage with floating pulse, spontaneous sweating, frequent urination, vexation, slight aversion to cold, and cramped legs, treated wrongly with Guizhi Tang (Cinnamon Twig Decoction) to attack the exterior. If stomach qi disharmony causes delirious speech, give small amounts of Tiaowei Chengqi Tang (Harmonize the Stomach Order the Yellow Decoction). (Formula discussion in Jue section.)
Concurrent disease of three yang meridians: abdominal fullness, heaviness, difficulty turning, locked jaw, greasy face, delirious speech, and urinary incontinence. Diaphoresis worsens delirium; purgation causes sweating on the forehead and cold limbs. If spontaneous sweating occurs, Baihu Tang (White Tiger Decoction) is indicated. (See Heaviness section.)
Cold Damage after four or five days, sunken pulse with wheezing/fullness, sunken indicates interior. Counteracting with diaphoresis causes fluid loss and difficult defecation. Exterior deficiency and interior excess lead to delirious speech; Da Chengqi Tang is indicated. (See Constipation section.)
Cold Damage with string-like pulse, headache, and fever belongs to Shaoyang. Shaoyang disease cannot be treated with diaphoresis; sweating causes delirious speech. This relates to the stomach; harmony restores health, disharmony causes vexation and palpitations. (See Shaoyang Disease section.)
Excessive sweating leading to loss of yang and delirious speech should not be purged; use Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) to harmonize Ying and Wei and unblock fluids, leading to natural sweating and cure. Repeated excessive sweating causes yang loss and delirious speech; short pulse indicates death, harmonious pulse indicates survival.
Adverse conditions treated wrongly with sweating: mild cases recover, severe cases with disordered speech and dizziness die.

After Purging:
Cold Damage after eight or nine days, wrongly purged, leading to chest fullness, fright, difficulty urinating, delirious speech, and whole-body pain preventing turning; Chaihu Jia Longgu Muli Tang (Bupleurum with Dragon Bone and Oyster Shell Decoction) is indicated. (Formula discussion in Fright section.)

Heat Entering the Blood Chamber:
Yangming disease with bleeding and delirious speech indicates heat entering the blood chamber, with sweating only on the head; puncture Qimen (LR14) to drain excess. Natural sweating leads to cure. (Abdominal fullness, delirious speech, tight floating pulse also indicate puncturing Qimen. Concurrent Taiyang-Shaoyang disease, sweating causes delirious speech, string pulse, delirium persisting five-six days; puncture Qimen.)
Women with Wind Strike, fever, aversion to cold, menstruation arriving, seven-eight days later fever subsides, pulse slows, body cools, chest fullness like chest binding; puncture Qimen. If clear during day and delirious at night, do not harm stomach qi or upper jiao; self-resolution expected. Huoren Shu suggests Xiao Chaihu Tang (Minor Bupleurum Decoction). (See Women's Cold Damage section.)

Cold Damage unresolved for thirteen days, passing stages with delirious speech indicates heat; purge with decoction. If urine is clear, stool should be hard, yet diarrhea occurs with harmonious pulse, indicating doctor used pill purgatives incorrectly. If spontaneous diarrhea occurs, pulse should be faint/cold, but is harmonious, indicating interior excess; Tiaowei Chengqi Tang is indicated. (Cheng commentary: Passing stages means heat transmission completes. Delirium indicates Yangming stomach heat, treat with Chengqi formulas. Clear urine diverts fluids, stool should be hard, yet diarrhea indicates pill purgative use. Diarrhea with faint/cold pulse is deficiency-cold; harmonious pulse indicates not deficiency-cold, but intestinal deficiency/stomach heat協热利. Tiaowei Chengqi Tang clears stomach heat. "Interior excess" implies heat. "Partial seepage" implies leakage. Five contrasts exist: heat vs cold, soup vs pill, hard stool vs diarrhea, faint vs harmonious pulse, medicated purge vs spontaneous diarrhea. Readers should analyze carefully.)

Diarrhea with delirious speech: if pulse harmonious, hands/feet warm, urine clear, it is Yang type, use Chengqi to purge. If pulse faint/cold, Shaoyin lethargy, fire-induced delirium/difficulty urinating, it is Yin type, use tonifying harmonizing formulas. (Lethargy, diarrhea, delirium see Shaoyin Diarrhea section.)

Xu Shumi: A patient with Cold Damage diarrhea, fever, confusion, fatigue, delirious insomnia. Some diagnosed yin deficiency due to diarrhea. I said this is Xiao Chengqi Tang syndrome. Others questioned using purgatives for diarrhea. I cited Zhang Zhongjing: Diarrhea with delirium indicates dry feces, treatable with Xiao Chengqi Tang. Citing Suwen: Mild cases oppose, severe cases follow. Reverse is standard treatment, following is counter treatment. Emperor asked about counter treatment; Qibo answered: Obstructive for obstruction, unblocking for unblocking. Wang Bing noted: Internal intense heat causes persistent diarrhea; treat heat with cold, remove blockage with cold purgation. Once blockage clears, diarrhea stops—unblocking for unblocking. This fits perfectly.

Huoren Shu: Constipation, red urine, warm hands/feet, surging-rapid pulse, delirious speech; Tiaowei Chengqi Tang. Delirious speech without aversion to cold but aversion to heat; Baihu Tang. Post-sweating, body harmonious but delirious; Chaihu Guizhi Tang. Fire-forced delirium; Baihu Tang.

Haizang: For elderly, children, or deficient persons with Cold Damage, five-six days of coma,妄言, dysuria or strangury, restlessness, insomnia; Baihu Tang plus Gardenia (Zhi Zi) 1 qian.

Doumen: For febrile diseases and epidemics with restlessness, mania, running, epilepsy-like state, unstable speech, no sweat, or unconsciousness; use Renzhonghuang (Human Manure) sealed in jar, fired strongly for half day, cooled, ground, mixed with fresh water, taken orally. Repeat if needed.

Wu Qiu: For severe Cold Damage heat, vexation, phlegm, coma, delirium; Bamboo Juice (Zhuli) 1 cup, raw Tianhuafen juice 1 cup, or add Gold (Jinzi) 3-5 qian, decoct together. Note: Suitable for internal heat intolerant of purgation.

Tonifying Deficiency:
Suwen states: Delirious speech is due to qi deficiency and solitary talking. (Lou Quanshan noted: I cured dozens of delirium cases with Ginseng, Angelica, Atractylodes tonics. How can one indiscriminately use Huanglian Jiedu Tang or Chengqi formulas without distinguishing deficiency/excess?) Nanjing states: Loss of yang leads to seeing ghosts. (Zhongjing's loss of yang delirium shares this meaning.)

Haizang: Huang Tang treats Cold Damage with weeping, laughing, sighing, or disordered speech. People mistake this for delirium/manic speech, but it is spirit failing to reside in the house. Pulses are inconsistent, weak on pressure, thin/small on floating/sinking, all yin pulses. Severe cases use Tiaozhong Wan or Lizhong Wan. (Formulas in Tonification section.)

Danxi: Brother Zheng of Pujiang, age 20, September fever, headache, hallucinations. Doctor gave Xiao Chaihu Tang several doses, fever worsened. Patient was fat, pale, prominent bones, pulse string-large-rapid-excess. Pulse was not truly excess, caused by cold medicines. Illness due to fatigue; treat with warm tonics. Formula: Ginseng, Atractylodes (Monarch), Poria, Peony (Ministers), Astragalus (Assistant), Aconite (Envoy). One dose no change. Criticized for using Aconite with rapid/large pulse and thirst. I replied: Deficiency mistaken for cold medicine, fat patient, left pulse larger than right, urgent case. Must add Aconite/Ginseng/Atractylodes for effect. Second dose removed Aconite, large dose given. After 50 doses, profuse sweat, cured. Two months convalescence required. Another patient, May, delirium, high fever, immobility, craving cold drinks, surging-rapid pulse. Astragalus/Poria decocted thick, mixed with cold water. Three doses led to coma-like state, color unchanged, breath normal, woke next morning, cured. Lu Xiong post-sweat fever/delirium, Lv Zhongxiu post-sweat fever/delirium, Tao Mingjie post-fever confusion/mutism; all cured with Ginseng/Atractylodes/Angelica tonics. Indeed, 80-90% of delirium is deficiency.

Yin Syndrome:
Cold hands/feet, fine-micro pulse, delirium; Sini Tang (Four Reversal Decoction). Huoren Shu uses Baitong Tang. Haizang uses Astragalus plus Ginger.

Hou Fuzhi: Extremely deep-fine pulse, external heat/internal cold, spots on shoulders/back/chest, manic speech. Some thought heat rash/delirium. I said no: Yang forced by Yin up to lungs/skin causes spots; spirit unsettled causes manic speech, not delirium. Skin hot but cold to touch. Given Ginger/Aconite over days (~20 liang), profuse sweat, cured. Recurrence, deep-slow pulse, constipation 3-4 days; Lizhong Wan (half jin in 3 days), fully cured. Hou's mania was spirit loss (yin deficiency), not yang mania.

Diagnosis:
Fixed gaze, delirium, wheezing/fullness: death. Diarrhea: death.
Delirious speech, slight fever, floating-large pulse, warm hands/feet: survival. Cold limbs, sunken-fine pulse: death within a day.

Zhengsheng:
Dictionary defines Zheng as serious/frequent/earnest. Zhengsheng is repeating one matter earnestly. Spirit deficiency prevents changing topics,守着 one sound, unlike delirious chaos. This distinguishes deficiency/excess. Cheng's "Zheng-Wei sound" theory is far-fetched. Treatment follows Tonifying Deficiency section.

Wu Qiu: Generally, Zhengsheng is due to internal deficiency and impending qi collapse. Signs: cold hands/feet, deep-fine pulse, short breath, weak voice, difficult breathing—all signs of yuan qi collapse. Incontinence, coma,急促 breath, unconsciousness: death. If breath not急促, warm hands/feet, deep-fine-micro pulse: urgently use Aconite and double Ginseng. Or Jieqi Dan/Heixi Dan. Or concentrated Ginseng tea. If Aconite unsuitable, Sanbai Tang with double Ginseng.

Dai Yuanli: Delirium is Yang, Zhengsheng is Yin. Classics: Excess delirium, deficiency Zhengsheng. Delirium: chaotic, nonsensical, talking to air like seeing ghosts. Zhengsheng: earnest repetition, elderly talkative due to yang deficiency. Distinguishing them is easy, but excess interior heat and yin blocking yang can both cause disordered speech; differentiate by other signs. Constipation, red urine, fever/thirst,妄言: interior excess delirium. Normal urine, loose stool, irritability/fever,妄言: yang blocked yang delirium. Interior excess: Tiaowei Chengqi Tang. Severe heat/restlessness/thirst: Lizhong Tang. Non-Yangming, intermittent muttering post-sweat, fluid disharmony: do not purge. Use Chaihu Tang + Jianzhong Tang halves to harmonize Ying/Wei. Yang transmitting to Yin, diarrhea, cold limbs, disordered speech: though diarrhea, dry feces remain, must purge. Yin-within-Yang: Tiaowei Chengqi Tang. Blood stasis in interior, black stool, clear urine, lower abdominal pain, mania/delirium: Taohhe Chengqi Tang. Women Cold Damage fever, menstruation stopped, heat entering blood chamber, blood clotting, delirium: Xiao Chaihu Tang. Post-illness qi/spirit incomplete, dreaming loss of voice like nightmare: not delirium/Zhengsheng; Wendan Tang minus Zhusu plus Ginseng, or Liujunzi Tang.