【纲】仲景曰。阳明病。初欲食。小便反不利。大便自调。其人骨节疼。翕然如有热状。奄然
发狂。 然汗出而解者。此水不胜谷气。与汗共并。脉紧则愈。
【目】张介宾曰。伤寒发狂。本阳明实热之病。然复有如狂症者。虽似狂而实非狂。此中虚实
相反。最宜详辨。不可忽也。凡实热之狂。本属阳明。盖阳明为多气多血之经。阳邪传入胃腑。热
结不解。因而发狂。内经脉解篇曰。胃者土也。故闻木音而惊者。土恶木也。其恶火者。热甚也。
恶人者。以阳明厥则喘 。 则恶人也。其病甚。则弃衣登高。逾垣上屋。或数日不食。以四肢为诸
阳之本。阳盛则实。实则能登高也。弃衣而走。热甚于身也。妄言詈骂。不避亲疏而歌者。阳盛为
邪也。又曰。阴不胜阳。则脉流薄疾。并乃狂。又曰。邪入于阳则狂。是皆以阳明热邪。上乘心肺。
故令心志昏乱若此。此阳狂也。然伤寒病至发狂。是为邪热已极。使非峻逐火邪。则不能已。故但
察其大便硬结。或腹满而坚。有可攻之症。则宜以大小承气。或凉膈散、六一顺气汤之类。下之可
也。如无胀满实坚等症。而惟胃火致然者。则但以白虎汤、抽薪饮辈。泄其火邪自愈。
鳌按。此为水湿之病。其人胃本不虚。只因水气怫郁，郁极而发。奄者。忽也。言忽然而狂也。
【纲】仲景曰。太阳病。六七日。表症仍在。而反下之。脉微而沉。反不结胸。其人如狂者。
以热在下焦。少腹当硬满。小便自利者。下血乃愈。所以然者。以太阳随经。瘀热在里故也。抵当
汤主之。
太阳病。身黄。脉沉结。少腹硬。小便不利者。为无血也。不便自利。其人如狂者。血结症也。
抵当汤主之。
太阳病。不解。热结膀胱。其人如狂。忽自下。下者愈。其人不解者。
尚未可攻。当先解外。外解已。但少腹急结者。乃可攻之。宜桃仁承气汤。阳明病。其人喜忘者。必
有蓄血。所以然者。本有久瘀血。故令喜忘。屎虽硬。大便反易。其色必黑。宜抵当汤下之。
【目】朱肱曰。发狂有二症。阳毒发狂。蓄血如狂。其外症与脉皆不同。病患烦躁。狂走妄言。
面赤咽痛。脉实潮热。独语如见鬼状。此阳毒也。病患无表症。不发寒热。唇燥。但欲漱水。不欲
入咽。其脉微而沉。小腹硬满。小便反利。大便必黑。身黄发狂。此血证谛也。大抵伤寒当汗不汗。
热蓄在里。热化为血。其人喜忘而如狂。血上逆则喜忘。血下蓄则内争。甚则抵当汤丸。轻者桃仁
承气汤、犀角地黄汤。须取尽黑物为效。
血热蓄在膀胱。若用抵当汤。更须仔细。审其有无表症。若有蓄血症。而外不解。亦未可便用
抵当。宜桂枝汤解外。缘热在膀胱太阳经也。
张兼善曰。狂之所起。皆由阳盛。内经曰。阴不胜其阳。脉流薄疾。并乃狂也。又曰。邪入于
阳则狂。邪入于阴则喑。难经曰。重阳者狂。重阴者癫。脉经曰。阴附阳则狂。阳附阴则癫。病源
曰。阳邪并于阳则狂。阴邪并于阴则癫。即诸经之狂。为阳盛也明矣。伤寒热毒在胃。并于心脏。使
神不宁而志不定。遂发狂也。其或狂言目反直视。又为肾绝。汗出辄复热。狂言不能食。又若失志。
死。若此。则非药所及。
张介宾曰。如狂症。本非实热。发狂症。亦有轻重。如热结膀胱。其人如狂。及脉微而沉。反
不结胸。其人如狂二条。以太阳热邪不解。随经入腑。但未至发狂。故曰如狂。此以热搏血分。
蓄聚下焦。故宜下也。近见伤寒家。则别有如狂之症。古人未及言者。盖或由失志而病。其病在心也。
或由悲忧而病。其病在肺也。或由失精而病。其病在肾也。或由劳倦思虑而病。其病在肝脾也。此
其本病已伤于内。而寒邪复感于外。则病必随邪而起矣。其症如狂。亦所谓虚狂也。而虚狂症。则
外无黄赤之色。刚暴之气。内无胸腹之结。滑实之脉。虽或不时躁烦。而禁之则止。口多妄诞。而
声息不壮。或眼见虚空。或惊惶不定。察其上。则口无焦渴。察其下。则便无硬结。是皆精气受伤。
神魂失守之症。此与阳极为
狂如冰炭。而时医不察。但见错乱。便谓阳狂。妄行攻泻。必致杀人。凡治此者。须辨阴阳。其有
虚而挟邪者。邪在阳分。补中益气汤等。邪在阴分。补阴益气煎等。虚而无邪者。在阳分。四君、
八珍、十全大补等。在阴分。四物、六味、左归饮、一阴煎等。阴虚挟火者。加减一阴煎。方治之
宜。大略如此。而变症之异。则有言不能传者。能知意在言表。则知所未言矣。
凡身有微热。或面赤戴阳。或烦躁不宁。欲坐卧泥水中。然脉则微弱无力。此阴症似阳也。名
为阴躁。盖以阳虚于下。则气不归原。故浮散于上。而发躁如狂。速当温补其下。命门暖。则火有
所归。而病当自愈。若误用寒凉之药。则必死矣。
陈士铎曰。伤寒发狂。至登高弃衣詈骂。去生远矣。仲景以竹叶石膏汤救之。妙矣。盖阳明之
火最大。非大剂白虎不救。世人往往畏用。特小其剂。如何能救。故用石膏必须三四两或七八两一
剂。火势始能稍退。狂亦可少止。然石膏性猛。恐损胃气。必兼人参为妙。我更有一方。用白虎汤
之半。而另加药味。方名祛热生胃汤。石膏、元参、麦冬各三两。茯苓一两。人参、车前各五钱。
知母三钱。水煎。此方石膏、知母泻胃火。人参生胃气。元参去浮游之火。麦冬生肺阴。茯苓、车
前。引火下行于膀胱。从小便出。且火盛必渴。渴必多饮水。用此二味以分湿。则水流而火自随水以
散。方中泻火。又不伤气。似胜于白虎。一剂狂定。二剂渴减半。三剂渴止。火亦息。正不用四剂也。
凡有火热发狂。或汗如雨。口渴舌燥。或生芒剌者。此方投之立效。断不至死也。
鳌按。此四条。皆本太阳经症。但首条。误下热入。阳极扰阴。血燥而蓄于中。血病则知觉昏
昧而发狂。所谓表病传里者。二条。亦病在燥血内结。皆属下后热入于里者。三条。血气皆重。故
用桃仁承气以攻其里之结血。此则由于未下者。四条。喜忘乃发狂之根也。故虽未及发狂字。而
亦当次入款内。
四条。虽皆太阳症。然至热结。则 传入阳明矣。即如喜忘一症。当其喜忘时。尚属太阳。
迨阳明既病。而究其根由。因知前此太阳病时。已有喜忘之病
情也。
【纲】仲景曰。伤寒脉浮。医以火迫劫之。亡阳。必惊狂。起卧不安者。桂枝去芍药加蜀漆龙
骨牡蛎救逆汤主之。
【目】黄仲理曰。又有火邪发惊狂者。医以火于卧床下。或周身用火逼劫汗出。或熨而成火邪。
其人烦躁惊狂。起卧不安。仲景主方外。桂枝甘草龙骨牡蛎汤亦可。
凡灸及烧针后症似火劫者。兼用劫法治之。金匮风引汤尤良。柴胡加龙骨牡蛎汤更捷。
陶华曰。伤寒热毒。由胃并心。遂使神不宁。志不定。故发狂。始则少卧不饥。妄语妄笑。甚则
登高弃衣。越垣上屋。皆由独阳亢极。热毒所致。非大下不止。亦有当汗不汗。瘀热在里。下焦蓄
血如狂者。未至竟狂耳。
难经。重阳者狂。即阳毒。脉洪大。或数实。狂言错语。烦躁干呕。面赤咽痛。潮热发斑。或
下利黄赤。阳毒升麻汤、黄芩汤。时行热病。发狂。黑奴丸。经曰。太阳病不解。热结膀胱。如狂
而血下者。愈也。血症如狂。脉微身黄。唇燥漱水。无寒热。小腹满。小便不利。大便黑。犀角地
黄汤。甚者桃仁承气汤、抵当丸。取下黑物为效。
【纲】张仲景说：阳明病，起初想进食，小便反而不通利，大便正常。患者感到骨节疼痛，身体微微发热，突然发狂。如果随后汗出而病愈的，这是因为水湿之气不能胜过谷气，随着汗液一同排出，脉象紧实则是痊愈的征兆。
【目】张介宾说：伤寒引起的发狂，本质上是阳明实热的病症。然而又有“如狂”的症状，虽然看似发狂但实际上并非真正的发狂。这里的虚证和实证截然相反，必须仔细辨别，不可疏忽。凡是实热导致的发狂，本属于阳明经。因为阳明经是多气多血的经络，阳邪传入胃腑，热结无法解除，因而导致发狂。《黄帝内经·灵枢·经脉解篇》说：胃属土，所以听到木音就惊恐的人，是因为土恶木（五行相克）。厌恶火的人，是因为热势极盛。厌恶人的人，是因为阳明经气厥逆则喘息，喘息则厌恶人。病情严重时，会脱掉衣服、爬上高处、翻墙登屋，或者几天不吃饭，因为四肢是诸阳之本，阳气旺盛则充实，充实就能登高；脱衣奔跑，是因为身上热势极盛；胡言乱语、骂人、不顾亲疏地唱歌，是因为阳气过盛被邪气干扰。又说：阴不能胜阳，则血脉流动急迫，阴阳相并就会发狂。又说：邪气侵入阳分就会发狂。这些都是因为阳明的热邪上乘于心肺，导致心神志昏乱如此。这是阳狂。然而伤寒病发展到发狂，说明邪热已经极盛，如果不是用峻猛的方法驱逐火邪，就不能停止。所以只要观察到大便硬结，或者腹部胀满坚硬，有可以攻下的症状，就适宜使用大承气汤或小承气汤，或者凉膈散、六一顺气汤之类，通过泻下治疗即可。如果没有胀满实坚等症状，仅仅是因为胃火导致发狂的，那么就只用白虎汤、抽薪饮等方剂，泄去火邪自然痊愈。
沈金鳌按语：这是水湿之病。患者胃气原本不虚，只是因为水气郁结，郁积到极点而发作。“奄”的意思是忽然。说的是突然发狂。
【纲】张仲景说：太阳病，经过六七天，表证仍然存在，反而用了下法，脉象微而沉，反而没有形成结胸证。患者出现类似发狂的症状，这是因为热在下焦，少腹应当硬满，小便自利的，通过下血才能痊愈。之所以这样，是因为太阳随经入里，瘀热在里的缘故。主治方剂为抵当汤。
太阳病，身体发黄，脉象沉结，少腹硬，小便不利的，是没有瘀血。如果小便自利，患者出现类似发狂的症状，这是血结证。主治方剂为抵当汤。
太阳病，病邪未解，热结于膀胱，患者出现类似发狂，如果自行下血，病就好了。如果病邪不解，还不可以攻下，应当先解表。表解之后，只有少腹急结的，才可以攻下，适宜用桃仁承气汤。
阳明病，患者喜欢遗忘（健忘），必定有蓄血。之所以这样，是因为本来就有久瘀血，所以导致喜欢遗忘。大便虽然硬，但排便反而容易，颜色必定黑，适宜用抵当汤攻下。
【目】朱肱说：发狂有两种症状。阳毒发狂和蓄血如狂，它们的外症和脉象都不同。患者烦躁，狂跑乱走，胡言乱语，面红咽痛，脉实且潮热，独自说话像看见鬼怪一样，这是阳毒。患者没有表证，不发寒热，嘴唇干燥，只想含水漱口而不愿咽下，脉象微而沉，小腹硬满，小便反利，大便必黑，身体发黄发狂，这是血证的确凿证据。大抵伤寒应当发汗而没有发汗，热邪蓄积在里，热转化为血，患者喜欢遗忘并且像发狂一样。血上逆则喜欢遗忘，血下蓄则内部争斗，严重的用抵当汤或抵当丸，轻的用桃仁承气汤、犀角地黄汤，必须排出黑色的瘀血才算有效。
血热蓄积在膀胱，如果使用抵当汤，更需要仔细审查是否有表证。如果有蓄血症，而表证未解，也不可以立即使用抵当汤，适宜用桂枝汤解表。因为热在膀胱太阳经。
张兼善说：发狂的起因，都是由阳气过盛引起。《内经》说：阴不胜其阳，血脉流动急迫，阴阳相并就会发狂。又说：邪气侵入阳分就会发狂，邪气侵入阴分就会失音。《难经》说：重阳者发狂，重阴者发癫。《脉经》说：阴附阳则发狂，阳附阴则发癫。《诸病源候论》说：阳邪并于阳则发狂，阴邪并于阴则发癫。由此可见，各经的发狂，都是因为阳气过盛。伤寒热毒在胃，并入心脏，使神志不宁、意志不定，于是发狂。如果出现狂言、眼睛上翻直视，又是肾气绝的表现；出汗后随即发热，狂言不止，不能进食，又像是丧失意志，这是死证。如果是这样，就不是药物所能救治的了。
张介宾说：如狂症，本质上不是实热；发狂症，也有轻重之分。如热结膀胱，患者如狂，以及脉微而沉，反不结胸，患者如狂这两条，是因为太阳热邪未解，随经入腑，但未至真正发狂，所以称为如狂。这是因为热与血搏结，蓄聚在下焦，所以适宜用下法。近来见到伤寒医生，另外提出如狂的症状，这是古人没有提及的。大概有的因失志而病，病在心；有的因悲忧而病，病在肺；有的因失精而病，病在肾；有的因劳倦思虑而病，病在肝脾。这些情况是本病已伤于内，而寒邪又感于外，那么疾病必然随着邪气而起。其症状像发狂，也就是所谓的虚狂。而虚狂症，外表没有黄赤之色、刚暴之气，内部没有胸腹的结滞、滑实的脉象，虽然有时躁动烦乱，但制止后就停止，口中多说妄诞之言，但声音气息不壮，或者眼见虚空，或者惊惶不定。观察其上，口无焦渴；观察其下，二便无硬结。这都是精气受伤、神魂失守的症状。这与阳极发狂如同冰炭般对立，而当时的医生不加考察，只见错乱，就认为是阳狂，妄行攻下泻法，必定致人死亡。凡治疗此类病症，必须辨别阴阳。其中有虚而挟邪的，邪在阳分，用补中益气汤等；邪在阴分，用补阴益气煎等。虚而无邪的，在阳分，用四君子汤、八珍汤、十全大补汤等；在阴分，用四物汤、六味地黄丸、左归饮、一阴煎等。阴虚挟火的，用加减一阴煎。方治的大略如此，而变症的差异，则有言语无法传达的，能领会意在言外的意思，就知道那些没有说出来的了。
凡是身体有微热，或者面赤戴阳（真寒假热），或者烦躁不宁，想要坐在泥水中，但是脉象微弱无力，这是阴症似阳，名为阴躁。因为阳气虚于下，气不归原，所以浮散于上，而发躁像发狂。应当迅速温补下部，命门温暖，则火有所归，病应当自愈。如果误用寒凉药物，必定死亡。
陈士铎说：伤寒发狂，到了登高、脱衣、骂人的地步，离死亡已经很近了。张仲景用竹叶石膏汤来挽救，真是巧妙。因为阳明之火最大，不用大剂量的白虎汤不能挽救。世人往往畏惧使用，特意减小剂量，怎么能挽救得了呢？所以使用石膏必须三四两，或者一剂七八两，火势才能稍微退去，发狂也可以稍微停止。然而石膏性猛，恐怕损伤胃气，必须兼用人参才妙。我还有一个方子，用白虎汤的一半，另外加药味，方名叫祛热生胃汤。石膏、玄参、麦冬各三两，茯苓一两，人参、车前子各五钱，知母三钱，水煎服。这个方子中，石膏、知母泻胃火，人参生胃气，玄参去除浮游之火，麦冬生肺阴，茯苓、车前子引火下行进入膀胱，从小便排出。而且火盛必然口渴，口渴必然多喝水，用这两味药来分利湿气，那么水流而火自然随水消散。方中泻火又不伤气，似乎胜过白虎汤。一剂发狂定住，二剂口渴减半，三剂口渴止，火也熄灭，正好不需要第四剂。凡是因火热发狂，或者汗如雨下，口渴舌燥，或者生出芒刺的，此方投用立刻见效，绝不会致死。
沈金鳌按语：这四条，都本源于太阳经症状。但第一条，是误下后热邪内入，阳极扰阴，血燥而蓄积在中焦，血病则知觉昏昧而发狂，这就是所谓表病传里。第二条，也是病在燥血内结，都属于下法后热邪入里。第三条，血气皆重，所以用桃仁承气汤攻下其里的结血，这是由于未经过下法的。第四条，喜忘（健忘）是发狂的根本，所以虽然没有提到发狂二字，但也应当列入这一款内。
这四条，虽然都是太阳症，但到了热结的程度，就传入阳明了。就像喜忘这一症状，当它喜忘时，尚属太阳；等到阳明既病，再究其根由，才知道此前太阳病时，已有喜忘的病情。
【纲】张仲景说：伤寒脉浮，医生用火法强迫劫汗，导致亡阳，必定出现惊狂，坐卧不安的，主治方剂为桂枝去芍药加蜀漆龙骨牡蛎救逆汤。
【目】黄仲理说：又有因火邪导致惊狂的，医生在卧床下用火，或者周身用火逼迫出汗，或者熨烫而成火邪，患者烦躁惊狂，坐卧不安。除了张仲景的主方外，桂枝甘草龙骨牡蛎汤也可以使用。
凡是艾灸及烧针后的症状类似火劫的，兼用劫法治之。金匮风引汤尤其好，柴胡加龙骨牡蛎汤更快捷。
陶华说：伤寒热毒，由胃并入心，遂使神志不宁，意志不定，所以发狂。开始时则睡眠少不想吃东西，胡言乱语，胡说大笑，严重时登高脱衣，翻墙登屋，都是由独阳亢极，热毒所致，非用大下法不止。也有应当发汗而没有发汗，瘀热在里，下焦蓄血如狂的，但未至完全发狂罢了。
《难经》说：重阳者发狂，即阳毒，脉洪大，或数实，狂言错语，烦躁干呕，面红咽痛，潮热发斑，或者下利黄赤，用阳毒升麻汤、黄芩汤。时行热病发狂，用黑奴丸。经文说：太阳病不解，热结膀胱，如狂而血下者，病愈。血症如狂，脉微身黄，唇燥漱水，无寒热，小腹满，小便不利，大便黑，用犀角地黄汤。严重的用桃仁承气汤、抵当丸，取下黑色瘀血为效。
[Outline] Zhang Zhongjing said: In Yangming disease, the patient initially desires food, but urination is unexpectedly obstructed, while bowel movements remain normal. The patient experiences pain in the bone joints, a slight feeling of feverishness, and suddenly becomes manic (mania). If the illness resolves with subsequent sweating, it indicates that the water-dampness qi failed to overcome the grain qi, which was expelled together with sweat; a tight pulse signifies recovery.
[Commentary] Zhang Jiebin stated: Mania caused by cold damage originates from excess heat in the Yangming channel. However, there is also a condition resembling mania ("ru kuang"), which appears like mania but is not true mania. The distinction between deficiency and excess here is opposite and must be carefully differentiated without negligence. True mania due to excess heat belongs to the Yangming channel, as Yangming is a channel abundant in both qi and blood. When yang pathogenic factors transmit into the stomach fu-organ, heat binds and fails to resolve, leading to mania. The "Jingmai" chapter of the *Lingshu* states: The Stomach corresponds to Earth; thus, those who startle at the sound of wood do so because Earth fears Wood (Five Elements theory). Those who fear fire do so because heat is extreme. Those who dislike people do so because when Yangming qi rebels, panting occurs, and panting leads to aversion to others. In severe cases, patients discard their clothes, climb high places, scale walls and roofs, or go days without eating. Since the four limbs are the root of all yang channels, excessive yang leads to fullness, and fullness enables climbing high; discarding clothes and running indicates extreme heat in the body; speaking nonsense, cursing, and singing regardless of kinship indicates yang excess disturbed by pathogens. It further states: When yin cannot overcome yang, the pulses flow rapidly, and when they merge, mania ensues. It also states: When pathogens enter the yang aspect, mania occurs. All these indicate that yang-ming heat pathogens ascend to the Heart and Lung, causing such confusion of the mind and spirit. This is yang mania. However, when cold damage progresses to mania, it signifies that pathogenic heat has reached its peak. Unless fierce methods are used to purge the fire pathogen, it cannot cease. Therefore, if one observes hardened stool or abdominal fullness and hardness, indicating symptoms amenable to purgation, formulas such as Da Chengqi Tang (Major Order the Qi Decoction) or Xiao Chengqi Tang (Minor Order the Qi Decoction), or Liangge San (Cool the Diaphragm Powder) and Liu Yi Shunqi Tang (Six-One Smooth Qi Decoction) should be used to induce purgation. If there are no symptoms of fullness, hardness, or excess, but the mania is caused solely by stomach fire, then formulas such as Baihu Tang (White Tiger Decoction) or Chuxin Yin (Draw Fire Down Decoction) should be used to drain the fire pathogen, after which health will naturally return.
Shen Jin'ao's note: This is a disease of water-dampness. The patient's stomach qi is originally not deficient; it is merely that water qi stagnates, and upon reaching extremity, it erupts. "Yan" means sudden. It refers to sudden mania.
[Outline] Zhang Zhongjing said: In Taiyang disease, after six or seven days, if exterior symptoms persist and purgation is mistakenly applied, the pulse becomes faint and deep. Instead of forming a Jie Xiong (Chest Binding) syndrome, the patient exhibits symptoms resembling mania. This is because heat resides in the lower jiao, and the lower abdomen should be hard and full. If urination is free, healing occurs through the passage of blood. The reason for this is that the Taiyang pathogen follows the channels inward, resulting in blood stasis and heat in the interior. The principal formula is Didang Tang (Mighty Decoction to Overcome Stasis).
In Taiyang disease, if the body turns yellow, the pulse is deep and knotted, the lower abdomen is hard, and urination is obstructed, this indicates no blood stasis. If urination is free and the patient exhibits symptoms resembling mania, this is a Blood Binding Syndrome (Xue Jie Zheng). The principal formula is Didang Tang.
In Taiyang disease, if the pathogen remains unresolved, heat binds in the Bladder, and the patient exhibits symptoms resembling mania, spontaneous passage of blood leads to cure. If the pathogen does not resolve, attack is not yet appropriate; one should first release the exterior. Once the exterior is resolved, if only the lower abdomen feels urgent and knotted, then attack is permissible, using Tao Ren Chengqi Tang (Peach Kernel Order the Qi Decoction).
In Yangming disease, if the patient suffers from forgetfulness, there must be accumulated blood. The reason is pre-existing long-standing blood stasis, which causes forgetfulness. Although the stool may be hard, defecation is surprisingly easy, and the color is necessarily black. Didang Tang should be used to purge.
[Commentary] Zhu Gong stated: There are two types of mania: Yang Poison Mania and Accumulated Blood Resembling Mania. Their external symptoms and pulses differ. For Yang Poison Mania, the patient is irritable, runs wildly, speaks nonsense, has a red face and sore throat, a solid pulse with tidal fever, and speaks alone as if seeing ghosts. For Accumulated Blood Resembling Mania, the patient lacks exterior symptoms, has no chills or fever, dry lips, desires to rinse the mouth with water but not swallow, a faint and deep pulse, hard and full lower abdomen, free urination, black stool, yellow body, and mania. This is definitive evidence of a blood syndrome. Generally, in cold damage, if sweating is indicated but not performed, heat accumulates in the interior and transforms into blood. The patient becomes forgetful and resembles mania. Blood reversing upward causes forgetfulness; blood accumulating downward causes internal struggle. Severe cases require Didang Tang or Didang Wan (Pill); mild cases require Tao Ren Chengqi Tang or Xi Jiao Di Huang Tang (Rhinoceros Horn and Rehmannia Decoction). Efficacy is confirmed only when black material is discharged.
When blood-heat accumulates in the Bladder, caution is needed when using Didang Tang. One must examine whether exterior symptoms exist. If there is an accumulated blood syndrome but the exterior is unresolved, Didang Tang should not be used immediately. Instead, Guizhi Tang (Cinnamon Twig Decoction) should be used to release the exterior, as the heat resides in the Taiyang channel of the Bladder.
Zhang Jianshan stated: Mania arises from excessive yang. The *Neijing* states: When yin cannot overcome yang, pulses flow rapidly, and merging causes mania. It also states: Pathogens entering yang cause mania; pathogens entering yin cause aphonia. The *Nanjing* states: Double yang results in mania; double yin results in epilepsy. The *Maijing* states: Yin attaching to yang causes mania; yang attaching to yin causes epilepsy. The *Bingyuan* states: Yang pathogens merging with yang cause mania; yin pathogens merging with yin cause epilepsy. Thus, it is clear that mania in all channels is due to yang excess. In cold damage, heat toxins reside in the stomach and merge with the Heart, disturbing the spirit and stabilizing the will, leading to mania. If accompanied by delirious speech, eyes rolling back, and staring straight ahead, it indicates Kidney exhaustion. If sweating is followed by recurrent fever, continuous delirium, and inability to eat, resembling loss of will, death ensues. Such conditions are beyond the reach of medicine.
Zhang Jiebin stated: "Resembling mania" is essentially not excess heat; true mania has degrees of severity. Regarding heat binding in the Bladder causing "resembling mania," and the case of faint/deep pulse without Chest Binding but with "resembling mania," these occur when Taiyang heat pathogens fail to resolve, follow the channels into the fu-organs, but have not yet progressed to true mania, hence termed "resembling mania." This is heat clashing with the blood level, accumulating in the lower jiao, requiring purgation. Recently, some cold damage physicians have identified other forms of "resembling mania" not mentioned by ancients. These may arise from emotional distress affecting the Heart, grief affecting the Lung, essence loss affecting the Kidney, or fatigue/overthinking affecting the Liver and Spleen. In these cases, the root disease damages the interior, and cold pathogens invade the exterior, causing illness driven by the pathogen. The symptoms resemble mania, termed "deficiency mania." Deficiency mania lacks yellow/red complexion or aggressive demeanor externally, and lacks chest/abdominal binding or slippery/excess pulses internally. Although occasionally irritable, calming stops it; speech is absurd but voice is weak; visions of emptiness or panic occur. Upper signs show no scorched thirst; lower signs show no hard stool/urine. These are signs of damaged essence/qi and lost spirit. This contrasts sharply with extreme yang mania. Unobservant physicians mistake confusion for yang mania and use reckless purgation, causing death. Treatment requires distinguishing yin and yang. For deficiency with pathogenic retention: if in the yang aspect, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction); if in the yin aspect, use Buyin Yiqi Jian (Nourish Yin and Augment the Qi Decoction). For deficiency without pathogenic retention: if in the yang aspect, use Sijunzi Tang (Four Gentlemen Decoction), Bazhen Tang (Eight Treasures Decoction), or Shiquan Dabu Tang (Ten Significant Tonification Decoction); if in the yin aspect, use Siwu Tang (Four Substances Decoction), Liuwei Dihuang Wan (Six-Ingredient Pill with Rehmannia), Zuogui Yin (Left Restoring Drink), or Yiyin Jian (One Yin Decoction). For yin deficiency with fire, use Jiajian Yiyin Jian (Modified One Yin Decoction). This covers the general principles, though variable syndromes may defy description. Understanding the intent behind words reveals what is unsaid.
If there is slight fever, facial redness resembling floating yang (true cold/false heat), or irritability with a desire to sit in mud/water, but the pulse is faint and weak, this is yin syndrome mimicking yang, named Yin Zao (Yin Irritability). Due to yang deficiency in the lower part, qi fails to root and floats upward, causing irritability resembling mania. Rapid warming and tonification of the lower part is required. Warming the Mingmen (Gate of Life) allows fire to return, and the illness heals. Misusing cold/cool herbs leads to death.
Chen Shiduo stated: Cold damage mania progressing to climbing, discarding clothes, and cursing is far from survival. Zhang Zhongjing saved such cases with Zhuye Shigao Tang (Bamboo Leaf and Gypsum Decoction), which is ingenious. Yangming fire is the most potent; only large doses of Baihu Tang can save the patient. People often fear using it and reduce the dose, failing to save. Gypsum must be used in doses of 3–4 liang or even 7–8 liang per decoction to slightly subdue fire and calm mania. However, gypsum is harsh and may damage stomach qi; adding Ginseng is advisable. I propose another formula, Reheat Generating Stomach Decoction (Qure Shengwei Tang), using half the ingredients of Baihu Tang plus others: Gypsum, Xuanshen (Scrophulariae Radix), and Maidong (Ophiopogonis Radix) each 3 liang; Fuling (Poria) 1 liang; Renshen (Ginseng Radix) and Cheqian (Plantaginis Semen) each 5 qian; Zhimu (Anemarrhenae Rhizoma) 3 qian. Decoct in water. Here, Gypsum and Zhimu drain stomach fire; Renshen generates stomach qi; Xuanshen clears floating fire; Maidong generates lung yin; Fuling and Cheqian guide fire downward to the Bladder for excretion via urine. Since fire excess causes thirst and increased water intake, these two herbs separate dampness, allowing water flow to disperse fire. This formula drains fire without damaging qi, surpassing Baihu Tang. One decoction calms mania; two halves thirst; three stop thirst and extinguish fire. No fourth dose is needed. For any mania due to fire/heat, profuse sweating, dry/thirsty tongue, or thorny tongue coating, this formula acts immediately and prevents death.
Shen Jin'ao's note: These four clauses originate from Taiyang symptoms. The first involves mistaken purgation leading to heat entry, extreme yang disturbing yin, blood dryness, and accumulation in the middle, causing confusion and mania—this is exterior transmitting to interior. The second involves dry blood binding internally, also resulting from post-purgation heat entry. The third involves heavy blood/qi, requiring Tao Ren Chengqi Tang to attack internal blood binding, applicable to cases not previously purged. The fourth notes that forgetfulness is the root of mania; although "mania" is not explicitly stated, it belongs in this category.
Although all four are Taiyang symptoms, heat binding transmits to Yangming. For instance, during forgetfulness, it still belongs to Taiyang; once Yangming is diseased, analyzing the root reveals that forgetfulness existed during the prior Taiyang phase.
[Outline] Zhang Zhongjing said: In cold damage with a floating pulse, if the physician uses fire methods to force sweating, causing Yang collapse, the patient will inevitably experience fright and mania, with restlessness in sitting and lying. The principal formula is Guizhi Qu Shaoyao Jia Shuqi Longgu Muli Niujie Tang (Cinnamon Twig Decoction Without Paeony, Added with Pinellia, Dragon Bone, and Oyster Shell to Rescue Deviation).
[Commentary] Huang Zhongli stated: There are cases of fright and mania caused by fire pathogens. If physicians place fire under the bed, apply fire to the whole body to force sweating, or use moxibustion/ironing creating fire pathogens, the patient becomes irritable, frightened, manic, and restless. Besides Zhang Zhongjing's principal formula, Guizhi Gancao Longgu Muli Tang (Cinnamon Twig, Licorice, Dragon Bone, and Oyster Shell Decoction) may also be used.
For symptoms resembling fire coercion after moxibustion or burning needles, treat with coercion-resolving methods. Fengyin Tang (Wind-Driving Decoction) from the *Jingui Yaolue* is excellent; Chaihu Jia Longgu Muli Tang (Bupleurum with Dragon Bone and Oyster Shell Decoction) is faster.
Tao Hua stated: Cold damage heat toxins move from the Stomach to the Heart, disturbing the spirit and will, causing mania. Initially, there is little sleep, lack of appetite, and delirious laughter. Severely, patients climb high, discard clothes, and scale walls. This is caused by extreme solitary yang and heat toxins, requiring major purgation. Some cases involve failure to sweat when indicated, leading to blood stasis and heat in the interior, with lower jiao blood accumulation resembling mania, but not fully developing into mania.
The *Nanjing* states: Double yang results in mania, i.e., Yang Poison. Pulse is surging-large or rapid-solid, with delirious speech, irritability, dry retching, red face, sore throat, tidal fever, macules, or yellow-red diarrhea. Use Yangdu Shengma Tang (Yang Poison Cimicifuga Decoction) or Huangqin Tang (Scutellaria Decoction). For epidemic febrile diseases causing mania, use Heinu Wan (Black Slave Pill). The classic states: If Taiyang disease is unresolved, heat binds in the Bladder, and if resembling mania with blood passage, the illness resolves. For blood syndrome resembling mania with faint pulse, yellow body, dry lips desiring to rinse but not swallow, no chills/fever, full lower abdomen, obstructed urination, and black stool, use Xi Jiao Di Huang Tang. Severe cases use Tao Ren Chengqi Tang or Didang Wan, with efficacy marked by discharge of black material.