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The *Neijing* states: "When pathogenic factors invade the Yang aspect, mania ensues," and also: "Excessive Yang leads to mania." Mania in various meridians is caused by an excess of Yang. In cold damage diseases, heat toxins accumulate in the Stomach and disturb the Heart, leading to mania; this represents 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 and singing, and in severe cases, jumping over walls or roofs. These symptoms are caused by the extreme hyperactivity of solitary Yang, which cannot be resolved 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; in such cases, urination is necessarily free, but it is merely "resembling mania" rather than true mania. Alternatively, forced sweating through fumigation or hot compresses, or moxibustion and burning needles, may cause irritability, restlessness, and inability to lie still or sit comfortably; this is termed "Fire Pathogen." Each of these conditions has specific treatment protocols. If a patient speaks nonsense, stares straight ahead, experiences recurrent fever after sweating, speaks deliriously, and cannot eat, these are signs of death, beyond the reach of medicinal intervention.

In Yangming disease, if the patient desires food, yet urination is obstructed while defecation remains normal, accompanied by bone joint pain, a slight feverish sensation (Xi Xi), and sudden onset of mania followed by resolution upon sweating, this occurs because Water Qi fails to overcome Grain Qi, which exits together with sweat; if the pulse is tight, recovery ensues. Cheng Wuji commented: When external heat initially transmits to the Stomach in Yangming disease, Stomach heat consumes grain, leading to hunger and desire for food. If Yangming heat is excess, urine should be frequent and scanty, and stool hard. Here, however, urine is obstructed and stool is normal, indicating scattered heat that has not formed an excess pattern. Desire for food indicates abundant grain in the Stomach. The *Neijing* states: "Food enters Yin and generates Qi in Yang"; abundant grain leads to Yang excess, consuming fluids and reducing water. The *Neijing* further states: "Water enters the channels, and blood is formed"; insufficient water leads to weak Yin blood. The *Jingui Yaolue* states: "Obstruction of Yin Qi causes bone pain"; thus, bone joint pain indicates deficiency of Yin Qi. Heat intense at the exterior presents as Xi Xi fever; heat intense at the interior presents as Zheng Zheng fever. Here, heat is scattered and not localized to either exterior or interior, hence the Xi Xi feverish sensation. "Yan Ran" means suddenly. Sudden mania occurs because Yin fails to control Yang. The *Neijing* states: "When Yin cannot control Yang, pulses flow rapidly and violently, leading to mania." For Yangming accumulated heat forming an excess pattern, purgation is required for cure; for scattered heat not forming excess, resolution requires sweating, hence "suddenly resolving upon sweating." Equality of water and grain implies balanced Yin and Yang Qi. Water failing to overcome Grain Qi signifies Yin failing to overcome Yang. Sweating depletes Yang Qi, while a tight pulse indicates the generation of Yin Qi. When Yin and Yang Qi are balanced and neither dominates, health is restored, hence "joining with sweat, pulse tight, then cured."

Wang’s commentary: Water belongs to Yin Qi, Grain to Yang Qi. In cold damage, Yang is primary; water failing to overcome grain signifies Yin failing to overcome Yang, indicating gradual improvement. Thus, Yin Qi joins with sweat and disperses, resulting in a tight pulse. Tightness indicates Yin-cold. Why does this become heat entering the Fu organs? It is due to Yin Qi joining with sweat. Moreover, the tight pulse resembles the long pulse, which is the characteristic pulse of Yangming. Cheng’s annotation suggests that sweating depletes Yang and a tight pulse generates Yin, creating imbalance between Yin and Yang. Yet the text later states "Yin and Yang Qi are balanced, neither dominating," which seems contradictory.

In Taiyang disease, after six or seven days, if exterior symptoms persist, the pulse is faint and deep, there is no Jie Xiong (chest binding) syndrome, and the patient becomes manic, this is because heat is in the Lower Jiao. The lower abdomen should be hard and full, urination is free, and bleeding from below indicates cure. This happens because Taiyang pathogens follow the channels into the interior, causing blood stasis and heat; therefore, Dandang Tang is indicated (some suggest Taoren Chengqi Tang).

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

Zhang’s commentary: The above two patterns both belong to Lower Jiao blood stasis. Improper use of sweating methods—either failing to sweat when indicated, sweating too late, pulse strong but sweat minimal, or inadequate covering preventing sweating—prevents Taiyang pathogens from exiting, causing them to follow channels into the Fu organs and bind in the Bladder. Now, if the lower abdomen is hard and full: if urination is obstructed, blood does not stagnate; if urination is free, it is a blood stagnation pattern. If blood does not stagnate, heat forces blood to discharge spontaneously; once blood discharges, heat exits with it, leading to cure. If blood stagnates and does not discharge, and the condition persists, internal attack is still contraindicated until exterior is resolved. Only after exterior resolution, if the lower abdomen remains urgent and knotted, should Taoren Chengqi Tang be used to attack. This addresses "resembling mania." True "mania" is different: although exterior symptoms exist, the pulse is faint and deep, indicating pathogen transmission to the interior; attacking internally leads to cure, hence Dandang Tang is used.

In Taiyang disease, if the body is yellow, pulse is deep and knotted, lower abdomen is hard, and urination is obstructed, this is not a blood pattern. If urination is free and the patient resembles mania, this is definitively a blood pattern, treated with Dandang Tang.

In cold damage, if the pulse is floating and fire therapy is used to force sweating, causing Yang collapse,惊狂 (panic and mania) and restlessness occur; treat with Guizhi Tang removing Shaoyao, adding Shu Ki, Longgu, and Muli to save the counterflow (see Palpitations section). Patients prone to sweating who undergo repeated sweating will experience mental confusion and urinary pain after voiding; treat with Yuyuli Wan (see Pi Syndrome section).

Appendix: Yang Du (Yang Toxin). The *Huren* 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, use Yang Du Shengma Tang or Hei Nu Wan; for interior patterns, use Dahuang San. Yang Renzhai uses Tingli Kujiu Tang, Zhizi Ren Tang, Sanhuang Tang, Dahuang San, Shengma Gegen Tang plus Dahuang. For manic running, induce vomiting of phlegm using Gouti powder mixed with water.

This section: Treats cold damage mania where patients discard clothes, run wildly, climb walls and roofs; use Que Shi San.
Coptis Rhizoma (Huanglian) and Calcitum (Han Shui Shi) in equal parts.
Grind into fine powder. Take 2 qian per dose, mix with cooled thick decoction of Licorice Root (Gancao).

Yun: For cold damage heart-wind mania, use Fangfeng Huanglian Tang.
Coptis Rhizoma (Huanglian), Rhubarb Radix et Rhizoma (Dahuang), Saposhnikovia Root (Fangfeng), Polygalae Radix (Yuanzhi), and Poria (Fushen), each 0.5 liang. Grind into powder. Take 1 liang per dose, decoct in water.

Haizang: Huang Tang treats cold damage with singing, laughing, crying, delirium, and nonsense speech (see Fever section).

Chen Zhirén treated cold damage mania where patients desired to run wildly, requiring four or five people to restrain them; pulse was deficient and rapid. Using Chaihu Tang worsened the condition. Switching to a decoction of Ginseng Radix (Renshen), Angelicae Sinensis Radix (Danggui), Atractylodis Macrocephalae Rhizoma (Baizhu), Licorice Root (Gancao), and Tangerine Peel (Chenpi) stopped the mania after one dose and promoted sleep after the second.

Collapse of Yang leads to seeing ghosts; collapse of Yin leads to mania. Severe tonification of Yin is required, such as Tiandi Jian (made from Asparagi Radix [Tianmendong] and Rehmanniae Radix [Dihuang]).

Yin Syndrome: Disease originates in Shaoyin and should not be treated with sweating. Seeing chills, the physician forcibly induces sweating, causing profuse leakage. Yang collapse results in mania, similar to extreme Yin causing agitation. Use medicines for Yin agitation combined with sweat-retaining agents like Yupingfeng San plus 1 qian prepared Aconite Root (Shu Fuzi). Apply warm powder externally. If cold sweat pours out, limbs are cold, and mania persists, use Sini Tang administered cold.

Mania with superficial heat that feels cold to the touch, or with ten or more spots on shoulders, back, chest, and diaphragm, and an extremely fine and deep pulse, is treated with Ganjiang Fuzi Tang containing Ginseng Radix (Renshen), administered cold.