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(Mingyang disease refers to the excess syndrome of the stomach and intestines. When the stomach qi is in excess, delirium occurs; therefore, delirium should be classified under Mingyang disease.)

Cheng Wuji: Delirium (Shanyu) refers to muttering speech during sleep or while awake. Another interpretation suggests that delirium refers to nonsensical speech caused by hallucinations. These conditions arise because excessive heat in the stomach rises to affect the heart, disturbing the spirit (Shen), leading to confusion and erroneous speech. In mild cases, there is only muttering during sleep; in severe cases, nonsensical speech occurs even when awake. The classics mention delirium, solitary talking, manic speech, continuous speech, and incoherent speech as resulting from varying degrees of heat pathogen severity. (Delirious and confused speech, if occurring with some order like conversing with others, or speaking alone as if seeing ghosts, indicates a milder heat pathogen. Manic speech with loss of consciousness, even shouting and continuous speech, indicates severe heat. Incoherent speech involves cursing and insulting without distinction between kin and strangers, indicating that the spirit is severely disturbed and difficult to restore.)

The causes of delirium vary. Some result from fire therapy forcing sweat, some from excessive sweating, some from diarrhea, some from bleeding, some from dry feces in the stomach, some from concurrent diseases of three Yang meridians, some from passing through stages without resolution, and some from collapse of Yang qi. These situations are detailed later, so they are not repeated here. In such cases, if the pulse is short, the prognosis is poor; if the pulse is harmonious, recovery is expected. If the body has slight fever and the pulse is floating and large, life is preserved; if limbs are cold and the pulse is sunken and fine, death may occur within a day. Alternatively, rebellious Qi causing wheezing and fullness, or sinking Qi causing spontaneous diarrhea, are all adverse signs.

Mingyang stomach excess with tidal fever requires purgation.
In Mingyang disease, with delirium and tidal fever, and a slippery and rapid pulse, Xiao Chengqi Tang (Minor Order the Stomach Decoction) is the primary treatment. Administer one cup of Xiao Chengqi Tang. If gas moves in the abdomen (shifting wind), administer another cup; if no gas moves, do not continue administration. If the next day there is still no bowel movement and the pulse becomes slightly choppy and coarse, it indicates interior deficiency, which is difficult to treat; do not administer Chengqi decoctions again.
In Mingyang disease, with delirium and tidal fever, if the patient cannot eat, it indicates dry feces in the stomach; if the patient can eat, the stool is merely hard. Da Chengqi Tang (Major Order the Stomach Decoction) should be used for purgation.
In concurrent disease of two Yang meridians, after Taiyang symptoms resolve, presenting only with fever, continuous sweating on hands and feet, difficulty in defecation, and delirium, purgation leads to cure; Da Chengqi Tang is indicated.
In Mingyang disease, if the patient sweats excessively, fluids exit, causing stomach dryness and hard stools, leading to delirium, Xiao Chengqi Tang is the primary treatment. If delirium stops after one dose, do not administer further.

Stomach excess with profuse sweating requires purgation.
Sweating accompanied by delirium indicates dry feces in the stomach due to wind pathogen. Purgation must wait until the exterior stage has passed. Premature purgation leads to language disorder because the exterior is deficient and the interior is excess; thus, purgation leads to cure, and Da Chengqi Tang is indicated. Excess leads to delirium; deficiency leads to Zhengsheng (repetitive speech). (Delirium refers to chaotic speech without pattern, frequently changing topics. Zhengsheng refers to earnest and repetitive speech, repeating the same phrase continuously. This is because abundant spirit allows for variability and chaotic speech, while deficient spirit lacks variability and repeats only one sound.)
In Cold Damage four to five days ago, with a sunken pulse and wheezing/fullness, sunken indicates interior location, but contrary use of diaphoresis causes fluid loss, difficulty in defecation, exterior deficiency and interior excess, leading to delirium over time. (Cheng believed Zhengsheng referred to Zheng-Wei sounds, which is incorrect, as clarified previously.)

Post-fire therapy:
Symptoms resemble Cold Damage, but the pulse is not wiry-tight but weak. Weak pulse implies thirst; fire therapy will definitely cause delirium. Weak pulse with fever and floating pulse indicates resolution through sweating.
After Taiyang disease undergoes fire-induced sweating, presenting with yellow skin, difficult urination, dry body, head sweating, abdominal fullness, slight wheezing, or constipation, long-term delirium may occur. (See "Head Sweating" section.)
On the second day of Taiyang disease, irritability appears; back ironing causes profuse sweating, fire heat enters the stomach, depletes stomach fluids, causing irritability and delirium. After ten-plus days, trembling and spontaneous diarrhea indicate impending resolution.
Shaoyin disease with cough, diarrhea, delirium, and difficult urination results from fire Qi forcing sweat. After vomiting, purging, sweating, or warm needle therapy, if delirium occurs and Chaihu syndrome resolves, this is a damaged disease; treat according to the deviation. (See Damaged Syndrome section.)

Post-sweating:
Cold Damage with floating pulse, spontaneous sweating, frequent urination, mental restlessness, slight aversion to cold, and cramped legs, treated incorrectly with Guizhi Tang (Cinnamon Twig Decoction) to attack the exterior. If stomach Qi disharmony causes delirium, give small amounts of Tiaowei Chengqi Tang (Regulate the Stomach Order the Stomach Decoction). (Formula discussion in "Jue" section.)
Concurrent disease of three Yang meridians presents with abdominal fullness, heaviness, difficulty turning, insensitivity around the mouth, greasy face, delirium, 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. (Discussion in "Body Heaviness" section.)
Cold Damage four to five days ago, with sunken pulse and wheezing/fullness, sunken indicates interior, but contrary diaphoresis causes fluid loss, difficulty in defecation, exterior deficiency and interior excess, leading to delirium; Da Chengqi Tang is indicated. (See "Constipation" section.)
Cold Damage with wiry pulse, headache, and fever belongs to Shaoyang. Shaoyang should not be diaphoresed; diaphoresis causes delirium. This belongs to the stomach; if stomach harmonizes, cure ensues; if not, irritability and palpitations occur. (See Shaoyang Disease section.)
Excessive sweating leading to Yang collapse with delirium should not be purged; instead, Chaihu Guizhi Tang (Bupleurum and Cinnamon Twig Decoction) harmonizes Ying and Wei to unblock fluids, leading to natural sweating and cure. Repeated sweating causing Yang collapse with delirium and short pulse indicates death; harmonious pulse indicates survival.
Adverse conditions treated with sweating: mild cases recover; severe cases with language disorder and dizziness die.

Post-purging:
Cold Damage eight to nine days, mistreated with purgation, presenting with chest fullness, fright, difficult urination, delirium, whole-body pain, and inability to turn, use Chaihu Jia Longgu Muli Tang (Bupleurum plus Dragon Bone and Oyster Shell Decoction). (Formula discussion in "Fright" section.)

Heat Entering the Blood Chamber:
Mingyang disease with bleeding and delirium indicates Heat Entering the Blood Chamber. Only head sweating occurs; puncture Qimen (LR14) to drain excess. Natural sweating leads to cure. (Abdominal fullness, delirium, floating-tight pulse also indicate Qimen puncture. Concurrent Taiyang-Shaoyang disease, diaphoresis causes delirium, wiry pulse, delirium persisting five to six days, puncture Qimen.)
Women with Wind Strike, fever, aversion to cold, menstruation arriving, seven to eight days later, heat subsides, pulse slow, body cool, chest full like Tie Xiong syndrome, puncture Qimen. Clear mind by day, delirium by night; do not violate Stomach Qi or Upper Jiao, self-resolution expected. Huoren Shu recommends Xiao Chaihu Tang (Minor Bupleurum Decoction). (Discussion in Women's Cold Damage section.)

Cold Damage unresolved for thirteen days, passing stages with delirium indicates heat; purgation with decoction is required. If urination is clear, stool should be hard; if diarrhea occurs instead and pulse is harmonious, the physician likely used pill-based purgatives, which is incorrect. If spontaneous diarrhea occurs and pulse should be faint/cold but is harmonious, this is interior excess; Tiaowei Chengqi Tang is indicated. (Cheng Wuji notes: Passing stages means completing transmission cycles. Delirium indicates Mingyang stomach heat; purge with Chengqi decoctions. Clear urination diverts fluids, stool should be hard; diarrhea suggests pill purgatives. Faint/cold pulse indicates deficiency-cold; harmonious pulse rules this out. Interior heat with diarrhea requires Tiaowei Chengqi Tang to clear stomach heat. "Interior excess" implies heat. "Biased seepage" implies leakage. Five contradictions exist: heat vs. cold, decoction vs. pill, hard stool vs. diarrhea, faint vs. harmonious pulse, medicated vs. spontaneous diarrhea. Readers should analyze carefully.)

Diarrhea with delirium: Harmonious pulse, warm extremities, clear urination indicate Yang; use Chengqi purgation. Faint/cold pulse, Shaoyin desire to sleep, fire-induced delirium, difficult urination indicate Yin; use tonifying harmonizing formulas. (Desire to sleep, diarrhea, delirium see Shaoyin Diarrhea section.)

Xu Shumi: A patient with Cold Damage diarrhea, fever, confusion, lethargy, delirium, and insomnia was diagnosed with Yin deficiency by some. I stated this is Xiao Chengqi Tang syndrome. Others questioned using purgatives for diarrhea. I cited Zhang Zhongjing: Diarrhea with delirium indicates dry feces; Xiao Chengqi Tang resolves it. Citing Suwen: Treat mild cases oppositely, severe cases similarly. Zhengzhi (direct treatment) vs. Fan Zhi (contrary treatment). Wang Bing注释: Internal heat binding causes diarrhea; cold clears heat and binding. Once bound disperses, diarrhea stops; Tong Yin Tong Yong (treat obstruction with unblocking method) applies.

Li Dongyuan: Constipation, red urine, warm extremities, surging-rapid pulse indicate delirium; Tiaowei Chengqi Tang. Delirium without aversion to cold but with aversion to heat; Baihu Tang. Post-sweating, body harmonious but delirious; Chaihu Guizhi Tang. Fire-forced delirium; Baihu Tang.

Zhang Yuansu: For elderly, children, and deficient persons with Cold Damage, five to six days of coma, wild speech, dysuria or retention, restlessness, insomnia; Baihu Tang plus Gardenia (one qian).

Liu Wansu: For febrile diseases and epidemics with mental agitation, mania, running, epilepsy-like state, unstable speech, prolonged lack of sweat, or unconsciousness in epidemics; use Renzhonghuang (Manure Yellow) sealed in clay pot, fired for half a day, cooled, ground to powder, mixed with fresh water (three qian). Repeat if necessary. (Renzhonghuang is human excrement.)

Wu Youke: For severe Cold Damage heat, irritability, phlegm, confusion, delirium; Bamboo Sap (one cup) plus raw Tianhuafen juice (one cup), or add Gold (three to five qian) and decoct. Note: Applicable for internal heat intolerant of purgation.

Tonifying Deficiency:
Suwen states: Delirium is due to Qi deficiency and solitary speech. Lou Quanshan noted successful treatments with Ginseng, Astragalus, Angelica, Atractylodes, questioning the indiscriminate use of Coptis Decoction or Chengqi formulas without distinguishing deficiency/excess. Nan Jing states: Collapse of Yang leads to seeing ghosts. Zhang Zhongjing's Yang collapse delirium shares this meaning.

Zhang Yuansu: Huang Tang treats Cold Damage with alternating crying/laughing, sighing, or disordered speech. People mistake this for delirium/manic speech, but it is actually spirit not residing in its chamber. Pulse floating/sinking inconsistent, weak upon pressure, both superficial and deep pulses diminished indicate Yin pulse. Severe cases use Tiaozhong Wan or Lizhong Wan. (Formulas in Tonification section.)

Zhu Danxi: Brother Zheng of Pujiang, age 20, September fever, headache, hallucinating ghosts, treated with Xiao Chaihu Tang multiple doses, heat worsened. Examination: Fat, pale complexion, prominent bones, wiry-large-rapid-solid pulse. Pulse was not truly solid but caused by cold medicines. Illness due to fatigue; treated with warm tonics. Formula: Ginseng, Atractylodes (monarch), Poria, Peony (ministers), Astragalus (assistant), Aconite (envoy). One dose showed no improvement. Critics argued against Aconite due to rapid pulse, high fever, and thirst. I replied: This is deficiency mistaken for excess by cold meds. Urgent case requires Aconite and Ginseng/Atractylodes for quick effect. Second dose removed Aconite, increased dosage. After fifty doses, profuse sweating cured him. Two months of tonification restored health. Another case: May delirium, high fever, immobility, craving cold drinks, surging-rapid pulse. Astragalus and Poria decocted thick, taken with cold water. Three doses led to coma-like state but normal color/breath; woke next morning, symptoms resolved. Lu, Lv, Tao post-sweating delirium/confusion cured with Ginseng, Astragalus, Atractylodes, Angelica tonics. Indeed, 80-90% of delirium cases are deficiency.

Yin Syndrome:
Cold extremities, fine-subtle pulse with delirium; Sini Tang (Reverse the Extremity Decoction). Huoren Shu uses Bitong Tang. Haizang uses Astragalus plus Ginger.

Hou Fuzhi: Extremely sunken-fine pulse, external heat/internal cold, spots on shoulders/back/chest, manic speech. Some thought spotted delirium was heat. I said: No. Yang forced by Yin up into Lung, transmitting to skin, causing spots. Spirit unsettled causes manic speech, not true delirium. Skin hot but cold to touch. Treated with Ginger/Aconite for days (approx. 20 liang), profuse sweating cured. Recurrence with sunken-slow pulse, constipation; Lizhong Wan cured. Hou's mania was spirit loss (Yin deficiency), not Yang mania.

Diagnosis:
Fixed gaze, delirium, wheezing/fullness indicate death. Diarrhea also indicates death. Delirium, slight fever, floating-large pulse, warm extremities indicate survival. Cold limbs, sunken-fine pulse indicate death within a day.

Zhengsheng (Repetitive Speech):
Dictionaries define Zheng as earnest/repetitive. Zhengsheng is repeating one topic earnestly due to insufficient spirit energy, unable to change, unlike delirium's chaos. This distinguishes deficiency from excess. Cheng's view of Zheng-Wei sound is flawed. Treatment follows the Tonifying Deficiency section.

Wu Youke: Generally, Zhengsheng results from internal deficiency and impending Qi collapse. Signs include cold extremities, sunken-fine pulse, short breath, weak speech, inability to respond. All indicate collapsing Yuan Qi. Incontinence, coma,急促 breathing indicate death. If breathing not急促, warm extremities, sunken-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 is chaotic, incoherent, talking to air like seeing ghosts. Zhengsheng is earnest repetition. Elderly rambling due to Yang deficiency. Distinguishing them is easy, but Yang excess interior excess and Yin excess blocking Yang can both cause disordered speech; differentiate by other signs. Constipation, red urine, fever, thirst, wild speech = interior excess delirium; purgative Tiaowei Chengqi Tang. Normal urination, loose stool, irritability/fever, wild speech = Yang blocking Yang delirium; warm Lizhong Tang. Non-Mingyang, intermittent delirium post-sweating due to fluid disharmony; do not purge. Use Chaihu Tang and Jianzhong Tang halves to harmonize Ying/Wei. Yang transmitting to Yin, diarrhea, cold limbs, disordered speech; though diarrhea, dry feces remain; purge Yin-within-Yang with Tiaowei Chengqi Tang. Blood stasis in interior, black stool, clear urination, lower abdominal pain, mania-like delirium; Taohhe Chengqi Tang. Women Cold Damage fever, menstruation stopping, Heat Entering Blood Chamber, blood binding, delirium; Xiao Chaihu Tang. Post-illness Qi/Spirit incomplete, dream voice loss like sleep paralysis; not delirium/Zhengsheng; Wendan Tang minus Scutellaria/Bamboo Sap plus Ginseng, or Liujunzi Tang.