Library

Both Shanghan (Cold Damage) and Wenyi (Warm Epidemic) present with symptoms of delirium (speaking incoherently due to mental confusion) and coma (loss of consciousness). Commentators often attribute these to Yangming Stomach Excess Syndrome (a pattern characterized by excess heat in the stomach and intestines). However, one must carefully distinguish the deficiency or excess of the pulse, the degree of fever, and the duration of the illness; it is inappropriate to generalize all cases as Yangming Stomach Excess.

If the pulse is indeed surging (Hong) and forceful, feeling very solid upon deep pressure, treatment should follow the principles for Yangming Stomach Excess. The heat steaming upward from the stomach affects the Yuan Shen (Original Spirit residing in the brain) and Shi Shen (Conscious Spirit residing in the heart), leading to coma, delirium, and loss of awareness. It may also be accompanied by severe dry fecal impaction. This indicates not only stomach excess but also intestinal excess, which obstructs Kidney Qi from ascending to communicate with the Heart. Consequently, hyperactive Yang becomes uncontrolled, causing mental agitation and delirium, or lack of spirit, lethargy, and a sleep-like state. For such cases, a large dose of Baihu Tang (White Tiger Decoction) can be administered, following the method in *Shanghan Lun* of "one decoction taken in three doses": decoct until three bowls remain, divided into three warm intakes. If fecal impaction is severe, Dachengqi Tang (Major Order the Qi Decoction) or Xiaochengqi Tang (Minor Order the Qi Decoction) may be酌情 (discretionarily) used. (If impaction is mild, a large dose of Baihu Tang alone will facilitate bowel movement, and delirium/coma will resolve spontaneously.)

In some cases, the pulse shows definite excess heat, and the patient presents with coma and delirium, suggesting Baihu Tang might be suitable. However, if the pulse is additionally wiry (Xian) or rapid (Shu), or feels insufficiently solid upon deep pressure, Baizhu Jia Renshen Tang (White Tiger Decoction plus Ginseng) is appropriate. I once treated a farm boy who contracted Wenyi after excessive labor. His pulse was wiry and forceful, rapid at nearly six beats per breath cycle. He suffered from incessant delirium, speaking only of labor matters. Although Baizhu Jia Renshen Tang was initially planned, given the mid-summer season and his youthful Shaoyang constitution, I first prescribed Baihu Tang. After ingestion, the pulse strength decreased, but delirium worsened. Fortunately, his bowels had not yet moved. I urgently switched to Baizhu Jia Renshen Tang, doubling the dosage of Renshen (Ginseng). Decocted to three teacups and taken in three warm doses, he recovered after one full course. A wiry and rapid pulse indicates inevitable depletion of True Yin. Baizhu Jia Renshen Tang nourishes True Yin amidst blazing pathogenic heat, thereby reducing the heat. When pathogenic heat is intense, herbs like Xuanshen (Scrophulariae Radix), Shashen (Glehniae Radix), and Shengdihuang (Rehmanniae Radix Recens) cannot effectively nourish Yin because they cannot overcome the heat, leaving no way for Yin to grow. Only Baizhu Jia Renshen Tang achieves both nourishing Yin and clearing heat simultaneously, and facilitates the interaction between Lower Jiao True Yin and Upper Jiao hyperactive Yang, yielding swift results.

If the condition occurs after sweating, vomiting, or purging, even if the pulse is surging and solid, Renshen should be added when using Baihu Tang. I once treated a patient whose Wenyi heat transmitted to the Yangming channel, presenting with a surging, solid, and forceful pulse, delirium, and mental clouding. A large dose of Baihu Tang reduced the fever by half and weakened the pulse, but the rate increased to six beats per breath, and delirium worsened. Upon inquiry, I learned he had taken purgatives twice days earlier for syphilis. I immediately switched to Baizhu Jia Renshen Tang, again doubling Renshen (in previous cases, Renshen was doubled due to prior misuse of Baihu Tang; if Baizhu Jia Renshen Tang had been used initially, doubling would not have been necessary). Decocted to three cups and taken in three warm doses, he recovered after one course.

In cases of latent Qi disease where Kidney deficiency allows pathogens to invade the Shaoyin channel, suppressing Kidney Qi so it cannot ascend to harmonize with the Heart, the Heart pulse becomes weak. Dry heat stagnates internally without exteriorizing, causing closed-eye lethargy and occasional delirium. In winter, this is a Heat pattern of Shaoyin Shanghan; in spring, it is Shaoyin Wenyi. Treatment requires a large dose of Baizhu Jia Renshen Tang, decocted with fresh Baimaogen (Imperatae Rhizoma). Take three bowls, divided into multiple doses, for spontaneous recovery.

Some patients with Cold-Warm diseases present with high fever throughout the body, a surging and solid pulse, and coma with mutism. After cooling therapy reduces the fever and normalizes the pulse, if coma or delirium persists, there is likely concurrent encephalopathy (brain marrow/nerve pathology). Continue treatment targeting the brain marrow and nerves. I treated a student with Wenyi heat entering Yangming, showing a very solid pulse, coma, mutism, and inability to turn over in bed. Two doses of Baihu Tang reduced fever by 70-80% and pulse solidity by half, allowing him to move, but mental clarity remained poor. This suggested meningeal inflammation affecting nerves due to heat steaming upward. I switched to a small dose of Baizhu Jia Renshen Tang, adding Lingyangjiao (Saigae Tataricae Cornu) 2 qian (decocted separately and mixed in). One dose resulted in recovery. Another case involved a young child with three-day Wenyi, mild fever, seemingly forceful but not surging/solid pulse, yet profound lethargy and mutism. This was also Wenyi with meningitis. Given the mildness, Lingyangjiao 0.5 qian decocted in water cured him instantly.

In some Cold-Warm diseases, after transmission through all channels and impending sweating, if Lower Jiao Yin deficiency prevents harmony with Upper Jiao Yang to generate sweat, coma and delirium may occur. I treated a strong man who worked long distances in mid-summer, contracting Wenyi for ten days. He exhibited lethargy, delirium, unconsciousness, and restless hand movements. His pulse was wiry, floating, rapid (nearly six beats per breath), unreceptive to pressure, especially at the Chi positions. I prescribed a large dose of Yin-nourishing herbs: Xuanshen, Shengdihuang, Shanyao, Gouqi, and Tiandong. Taken as two doses in one day, he sweated and recovered that day.

If Cold-Warm disease treatments involve excessive use of dispersing, breaking, descending, or purging herbs, damaging the Da Qi (Great Qi) in the chest, coma or delirium may persist after the high fever subsides. I treated a man with Wenyi who took medicine for over twenty days. External heat cleared, but mental state deteriorated. Upon examination, his body was cold, breathing faint, unresponsive to calls, tongue dry like whetstone with no coating, pulse weak, slow (<4 beats per breath), requiring sighing every 5-6 breaths. This indicated damage to Da Qi by excessive descending drugs. Damaged Da Qi sank, failing to reach the brain (causing coma) or moisten the tongue root (causing dryness); failure to disseminate to Ying and Wei caused cold limbs; sighing compensated for constrained Qi. I prescribed Yetaishen (Wild Ginseng) 1 liang and Chaihu 1 qian, decocted and administered. Two doses led to full recovery. Another case: a youth contracted Shanghan in early spring, cured by another doctor, then relapsed due to overeating, cured by Baihu Tang. Three days later, severe relapse occurred with mental agitation, tremors, and incoherent speech. Pulse: Right Cun and Guan were weak, Guan particularly unreceptive. I diagnosed this not as disease recurrence, but as Qi deficiency from dietary restriction post-relapse. Feeding him resolved the issue. Family confirmed restricted diet due to fear of recurrence. I advised frequent, moderate feeding. Within ten hours, three meals cured him. Da Qi relies on Gu Qi (Food Qi) for cultivation; post-illness Qi deficiency lacks this support. The first case required tonifying and ascending Qi due to drug-induced damage; the second required dietary intervention due to lack of Gu Qi. Clinicians must carefully align treatment with pathogenesis.

In Warm diseases with rashes, toxic heat attacking internally confuses the Spirit. I treated a youth with Wenyi heat in Yangming. After repeated cooling, major fever subsided, but mental restlessness and eye-closed delirium persisted. Pulse showed residual heat with a tight quality, suggesting hidden rash toxin. I gave a small dose of Baihu Tang with Lingyangjiao powder 1 qian and Aspirin 2 fen. Rash erupted over the body, curing the disease. Another case: a young girl with Warm Rash. Rash faded next day, followed by lethargy and palpitations. Pulse: rapid and forceful. I prescribed Baihu Tang plus Lingyangjiao 1.5 qian (decocted separately), decocted with fresh Lugen (Phragmitis Rhizoma). Two tea cups, taken in three warm doses. Rash re-emerged, and she recovered.

Individuals with chronic Phlegm-Fluid retention may experience chaotic Spirit due to intense Cold-Warm heat interacting with Phlegm. Refer to the case studies attached to the Gua Lou Jie section.

In infectious Warm Epidemics, pathogens enter via nose/mouth, transmit from Lung to Heart, causing spontaneous laughter, mental agitation, disordered speech, hallucinations, and delusions. I treated an elderly woman with this presentation. Pulse: forceful, shaking at the Guan front. I prescribed Hu Xin Zhi Bao Dan (My Proprietary Heart-Protecting Precious Pill). One dose cured her.

The above covers the causes and treatments for coma and delirium in various Cold-Warm diseases. Adaptation and flexible application depend on the clinician's careful study.