【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。
[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.