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The *Neijing* states: "When pathogenic factors invade the Yang aspect, mania ensues," and further says, "Excessive Yang leads to mania." Mania in various meridians is caused by an excess of Yang. In cold damage diseases, heat toxins reside in the Stomach and merge into the Heart, leading to mania; this indicates extreme pathogenic heat.

The onset of mania manifests as little sleep, lack of appetite, delirious speech, unprovoked laughter, aimless walking, discarding clothes and running, climbing high places to sing, and in severe cases, jumping over walls or roofs. These symptoms are caused by the extreme hyperactivity of solitary Yang. Such conditions cannot be cured without emesis or purgation. There are also cases where sweating should have been induced but was not, resulting in blood stasis and heat accumulating in the Lower Jiao, presenting with symptoms resembling mania ("ru kuang"). In these cases, urination is necessarily free, representing merely a state of resembling mania rather than full-blown mania. Alternatively, forced sweating through fumigation, hot compresses, moxibustion, or cauterization may cause irritability, restlessness, and inability to lie still or sit comfortably; this is termed "Fire Pathogen." Each of these scenarios has specific treatment protocols. If a patient exhibits delirious speech, eyes fixed upward, recurrent fever after sweating, continuous delirium, and inability to eat, these are signs of death, beyond the reach of medicinal intervention.

In Yangming disease, the patient desires food, yet urination is obstructed while bowel movements remain normal. The person experiences joint pain and a slight feverish sensation. Suddenly developing mania, followed by sweating and resolution of the illness, occurs because the Water element fails to overcome the Grain Qi (Gu Qi); water and sweat are expelled together. A tight pulse indicates recovery.

Cheng Wuji notes: When external heat initially transmits to the Stomach in Yangming disease, Stomach heat consumes grain, causing hunger and desire for food. If Yangming heat becomes excessive and forms an excess pattern, urination becomes frequent and scanty, and stool becomes hard. Here, however, urination is obstructed and stool is normal, indicating that heat is diffuse and not forming an excess pattern. Desire for food implies abundant grain in the Stomach. The *Neijing* states: "Food enters the Yin and generates Qi in the Yang." Abundant grain leads to Yang excess; intense heat consumes body fluids, reducing water content. The *Neijing* says: "When water enters the meridians, blood is formed." Reduced water leads to weak Yin blood. The *Jingui Yaolue* states: "Obstruction of Yin Qi causes bone pain." Joint pain indicates insufficient Yin Qi. Heat prevalent at the exterior presents as mild fever (xi xi fa re); heat prevalent at the interior presents as steaming fever (zheng zheng fa re). Here, heat is diffuse, not localized strictly to exterior or interior, hence the mild feverish sensation. "Yan ran" means suddenly. Sudden mania occurs because Yin fails to control Yang. The *Neijing* states: "When Yin cannot overcome Yang, pulses flow rapidly and violently, leading to mania." For Yangming heat forming an excess pattern, purgation is required for cure. For diffuse heat not forming an excess, resolution requires sweating. Hence it is said: "Sweating resolves the condition."

Balance between water and grain ensures harmonious Yin and Yang Qi. Water failing to overcome grain signifies Yin failing to overcome Yang. Sweating reduces Yang Qi; a tight pulse indicates the generation of Yin Qi. When Yin and Yang Qi are balanced and neither dominates, health is restored, hence "with sweat combined, a tight pulse indicates recovery."

Wang’s commentary: Water represents Yin Qi, while grain represents Yang Qi. In cold damage, Yang is predominant. Water failing to overcome grain means Yin fails to overcome Yang, indicating gradual improvement. Thus, Yin Qi combines with sweat and disperses, resulting in a tight pulse. Tightness characterizes Yin-cold pulses. Although this involves heat entering the Fu organs, why is the pulse tight? Likely due to Yin Qi combining with sweat. Moreover, the tight pulse resembles the long pulse, which is the characteristic pulse of Yangming. Cheng Wuji noted that sweating depletes Yang and a tight pulse generates Yin; if Yang depletes and Yin generates, Yin and Yang become imbalanced. Yet the text later states "Yin and Yang Qi are balanced, neither dominating," which seems contradictory.

In Taiyang disease lasting six or seven days, if exterior symptoms persist, the pulse is faint and deep, and there is no chest binding, but the patient develops mania, it is because heat is located in the Lower Jiao. The lower abdomen should be hard and full, urination is free, and bleeding allows recovery. This happens because Taiyang pathogens follow the meridians, causing blood stasis and heat in the interior; thus, Dishuang Tang (Ephedra and Dogwood Twig Decoction) is indicated. (Some suggest Taoren Chengqi Tang).

If Taiyang disease remains unresolved and heat binds in the Bladder, the patient resembles mania. If blood passes spontaneously, the condition resolves. If exterior symptoms remain unresolved, attack is contraindicated; resolve the exterior first. Once the exterior is resolved, if only the lower abdomen feels urgent and knotted, attack may proceed using Taoren Chengqi Tang.

Zhang’s annotation: Or it is said that the above two patterns both belong to blood stasis in the Lower Jiao. Improper use of sweating methods—either failing to sweat when indicated, delaying sweating, having a vigorous pulse with faint sweating, or inadequate covering preventing sweat—prevents Taiyang pathogens from exiting. They follow the meridians into the Fu organs, binding in the Bladder. Now, if the lower abdomen is hard and full: if urination is obstructed, blood does not accumulate; if urination is free, it is a blood accumulation pattern. If blood does not accumulate, heat forces blood to pass spontaneously; blood passage allows heat to exit with it, resolving the condition. If blood accumulates and does not pass, and the area remains unresolved, attack is contraindicated until the exterior is resolved. Once the exterior is resolved and only lower abdominal urgency persists, Taoren Chengqi Tang is used to attack. This addresses "resembling mania." True "mania" differs: although exterior symptoms exist, the pulse is faint and deep, indicating pathogen transmission to the interior. Can we stop at resolving the exterior? Purging cures it; thus, Dishuang Tang is used.

In Taiyang disease, if the body is yellow, pulse is deep and knotted, lower abdomen is hard, and urination is obstructed, it is a non-blood pattern. If urination is free and the patient resembles mania, it is definitively a blood pattern; Dishuang Tang is indicated.

In cold damage with a floating pulse, if fire therapy is forcibly applied to induce sweating, loss of Yang inevitably leads to fright, mania, and restlessness. Guizhi Tang minus Shaoyao plus Shuqi, Longgu, and Muli Jiuni Tang (Cinnamon Twig Decoction minus Peony plus Arisaema, Dragon Bone, and Oyster Shell Rescue the Reversal Decoction) is indicated (formula discussion see Fright section).

Individuals prone to sweating who undergo heavy sweating again will suffer from mental confusion and urinary pain after voiding; Yuyuli Wan (Hematite Pill) is indicated (formula see Pi section).

Appendix: Yang Du (Yang Toxin). The *Huoren* book states: Patients with irritability, manic running, delirious shouting, red face, sore throat, nose like soot, skin spots like brocade, or bloody-yellow diarrhea suffer from Yang Du. For exterior patterns, Yang Du Shengma Tang (Cimicifuga Decoction for Yang Toxin) or Heini Wan (Black Slave Pill) are used. For interior patterns, Dahuang San (Rhubarb Powder) is used. Yang Renzhai uses Tingli Kujiu Tang (Descurainia and Vinegar Decoction), Zhizi Ren Tang (Gardenia Kernel Decoction), Sanhuang Tang (Three Yellow Decoction), Dahuang San, Shengma Gegen Tang plus Dahuang. For manic running, Gouti powder mixed with water induces vomiting of phlegm.

This section treats cold damage mania with discarded clothes, running, and climbing walls/roofs using Queshi San (Magpie Stone Powder):
Huanglian (Coptis Rhizome) and Hanshui Shi (Calcitum, 20g each).
Grind into fine powder. Take 2 qian per dose, mix with cold decoction of Gancao (Licorice Root), taken cool.

Yun’s note: For cold damage heart-wind mania, Fangfeng Huanglian Tang (Saposhnikovia and Coptis Decoction) is suitable:
Huanglian, Dahuang, Fangfeng, Yuanzhi, Fushen (15g each).
Grind into powder. Take 1 liang per dose, decoct in water.

Haizang: Huang Tang (Yellow Decoction) treats cold damage with singing, laughing, crying, or delirious speech (see Fever section).

Chen Zhirén treated cold damage mania where the patient wanted to run wildly, requiring four or five people to restrain them, with a deficient and rapid pulse. Chaihu Tang worsened the condition. Subsequently, a decoction of Renshen, Danggui, Baizhu, Gancao, and Chenpi cured the mania in one dose and ensured sleep in the second.

Loss of Yang causes visions of ghosts; loss of Yin causes mania. Severe tonification of Yin is required, such as Tiandi Jian (Heaven and Earth Decoction), made from Tianmendong and Dihuang paste.

Yin Pattern: This arises from Shaoyin disease, where sweating is inappropriate. Seeing chills, the physician forcibly induces sweating, causing leakage that does not stop. The patient loses Yang and becomes manic. This is similar to extreme Yin causing agitation. Treat with herbs for Yin agitation plus antiperspirants, such as Yupingfeng San with 1 qian of Shufu Zi (Prepared Aconite Root). Apply warm powder externally. If cold sweat pours out, limbs are cold, and mania persists, Sini Tang (Four Counterflow Decoction) should be administered cold.

Mania with hot skin surface but cold upon pressure, or with ten or more spots on shoulders/back/chest, and extremely fine/deep pulse, indicates Ganjiang Fuzi Tang (Dried Ginger and Aconite Decoction) administered cold with Renshen decoction.