五十九难曰∶狂癫之病，何以别之？
然∶狂疾之始发，少卧而不饥，自高贤也，
自辨智也，自贵倨也，妄笑好歌乐，妄行不休是也。癫疾始发，意不乐、直视僵仆，其脉三部阴阳
俱盛是也。
狂病属阳，始发之时，阳气盛不入于阴，故少卧。阳气并于上，故不饥。其自高贤，自辨智，
自贵倨，皆狂之意也。妄笑，好歌，妄行，皆狂之态也。病发于阳，阳性动，故其状皆有余，
即前二十难所谓重阳者狂是也。癫病属阴，始发之时，意不乐，癫之意也。直视僵仆，癫之态
也。病发于阴，阴性静，故其状皆不足，即二十难所谓重阴者癫是也。脉三部阴阳俱盛者，是
总上二者而言。谓发于阳为狂，则三部阳脉俱盛，发于阴为癫，则三部阴脉俱盛也。
按∶《素问·病能论》帝曰∶有病怒狂者，此病安生？岐伯曰∶生于阳也。帝曰∶阳何以使
人狂？岐伯曰∶阳气者，因暴折而难决，故善怒也，病名曰阳厥。帝曰∶何以知之？岐伯曰∶
阳明者常动，巨阳少阳不动，不动而动大疾，此其候也。帝曰∶治之奈何？岐伯曰∶夺其食即
已，使之服以生铁洛为饮，夫生铁洛者，下气疾也。此总论狂病属于阳气盛，阳气宜于升达，
若折抑之则病，其来太阳少阳之脉，动之不甚者而动且大疾，则阳明之脉常动者，其动甚，可
知为狂病将发之候。先当夺其食，使胃火弱而气衰，庶几阳动息而病可愈，甚则服以铁洛饮，
下气开结，而平木火之邪也。《灵枢·癫狂篇》曰∶狂始生，先自悲也，喜忘苦怒善恐者，得之
忧饥。此言阴虚则阳盛，以致病狂也。又狂始发，少卧不饥，自高贤也，自辨智也，自尊贵也，
善骂詈，日夜不休者，此心气之实狂也。又狂，言惊善笑，好歌乐，妄行不休者，得之大恐，
此言肾病上传于心，而为心气之实狂，以大恐则伤肾也。又狂，目妄见，耳妄闻，善呼者，少
气之所生也。此因肾气少，而致心气虚狂也。又狂者，多食，善见鬼神，善笑而不发于外者，
得之有所大喜。此言喜伤心志而为虚狂也。又狂而新发，未应如此者，先取肝经之曲泉左右动
脉，及甚者见血，有顷已，不已，灸骨 二十壮。此分论狂病虚实，治未发先清泄木气，而不
令及于心神也。《素问·通评虚实论》帝曰∶癫疾何如？岐伯曰∶脉搏大滑，久自已。脉小坚
急，死不治。曰∶癫疾之脉，虚实何如？曰∶虚则可治，实则死。此总论癫疾属于阴气盛，阴
盛则阳虚，故其脉搏指而大滑，心肝之阳未衰，有来复之象，故久而自已。若小坚急，纯阴无
阳。则死不治。脉虚者，邪亦虚，脉实者，邪亦实，实即坚急之意，故亦主死也。《灵枢·癫
狂篇》曰∶癫疾始生，先不乐，头重痛，视举目赤甚，作极已而烦心，候之于颜。此言厥气上
乘于天气，及太阳君火也。夫癫乃阴阳之气，先厥于下，后上逆于巅而为病，当候之于颜面气
色也。又癫疾始作，引口啼呼喘悸者，此言太阳主开，阳明主阖，乃厥气上乘，致开阖不清而
为病也。又癫疾始作，先反僵，因而脊痛者，此厥气逆于寒水之太阳，及寒气乘于地中也。又
治癫疾者，常与之居，察其所当取之处，病至视其有过者泻之，置其血于瓠壶之中，至其发时，
血独动矣，不动，灸 骨二十壮。此言治癫疾，当分天地水火之气而治之，太阳之火，日也，
随天气而日绕地一周，动而不息者也，地水者，静而不动者也，常与病居，察其病在手足何经，
其法致其血于瓠壶中，发时气相感则血动，是感天气太阳之运动也，当候之手太阳阳明太阴者
是也。不动者，病陷于地水之中，当候之足太阳阳明太阴者是也，更宜灸 骨二十壮，若不图
之于早，病成则难治。故《下经》之骨癫疾，筋癫疾，脉癫疾，多云不治也。若夫痫证，《素
问·奇病论》帝曰∶人生而有病癫疾者，病名曰何，安所得之？岐伯曰∶病名为胎病，此得
之在母腹中时，其母有所大惊，气上而不下，精气并居，故令子发为癫疾也。此论生而病癫痫，
为先天所受之病，孕妇受惊，精气上而不下，精与惊气并居而为病，故曰胎病也。然亦有不从
母腹中得之，若卒然闻惊而得者，盖惊则神出舍空，痰涎乘间而归之也。但痫证与癫厥异者，
仆时口作六畜声，将醒时吐涎沫耳。更有血迷似癫者，妇人月水崩漏过多，血气迷心，或
产后恶露上冲，而语言错乱，神志不宁者，血虚神耗也。又有心风似癫者，精神恍惚，喜怒
言语或时错乱，有癫之意，不如癫者之甚，皆痰气为病，不可不辨也。
答：狂病刚开始发作时，睡眠少且不觉得饥饿，自认为贤能，自认为聪明，自视高贵且傲慢，无故发笑、喜欢唱歌娱乐，行为狂妄不停歇，这就是狂病的表现。癫病刚开始发作时，心情不愉快、两眼直视、突然僵倒，脉象在寸关尺三部及阴阳部位都盛大有力，这就是癫病的表现。
狂病属于阳证，刚开始发作时，阳气旺盛而不能入于阴分，所以睡眠少。阳气并聚于上部，所以不觉得饥饿。那些自认为贤能、聪明、高贵傲慢的表现，都是狂病的神志特征。无故发笑、喜欢唱歌、行为狂妄，都是狂病的外在形态。病发于阳，阳的性质是动的，所以其症状都属于“有余”（实证），也就是前文第二十难所说的“重阳者狂”。
癫病属于阴证，刚开始发作时，心情不愉快，这是癫病的神志特征；两眼直视、突然僵倒，这是癫病的外在形态。病发于阴，阴的性质是静的，所以其症状都属于“不足”（虚证），也就是第二十难所说的“重阴者癫”。
所谓“脉三部阴阳俱盛”，是总括上述两种情况而言的。意思是说，如果是发于阳的狂病，则三部的阳脉都盛大；如果是发于阴的癫病，则三部的阴脉都盛大。
按语：《素问·病能论》中黄帝问：有人患怒而发狂的病，这种病是怎么产生的？岐伯回答：产生于阳邪。黄帝问：阳邪怎么会导致人发狂？岐伯说：人的阳气，因为突然受到挫折而难以疏泄，所以容易发怒，这种病名叫“阳厥”。黄帝问：怎么知道呢？岐伯说：阳明经的脉搏通常是跳动的，巨阳经（太阳）和少阳经的脉搏通常是不明显跳动的，如果不该跳动却跳动得特别快疾，这就是征象。黄帝问：怎么治疗？岐伯说：限制他的饮食就可以了，让他服用生铁洛制成的饮料。生铁洛的作用是降气疾速。这一段总体论述了狂病属于阳气盛。阳气适宜升发通达，如果受到折抑就会生病。其脉象来自太阳、少阳，原本不动却动得快疾，那么常动的阳明经脉搏动就非常剧烈，可以知道这是狂病将要发作的征兆。应当先通过限制饮食，使胃火减弱、气机衰退，这样阳动才能平息，病才可愈；严重时服用铁洛饮，以降气开结，平抑肝木心火之邪。
《灵枢·癫狂篇》说：狂病初起，先表现为悲伤，健忘，苦闷易怒，善于恐惧，这是由于忧愁和饥饿引起的。这是说阴虚导致阳盛，从而引发狂病。又说：狂病刚发作时，睡眠少且不饿，自视贤能聪明，自尊高贵，辱骂他人，日夜不停，这是心气实盛的狂病。还有种狂病，言语惊恐，喜欢笑，爱唱歌娱乐，行为狂妄不停，是由于大恐引起的，这是说肾病传变到心，导致心气实盛而狂，因为大恐会伤肾。还有种狂病，眼睛看到不存在的东西，耳朵听到不存在的声音，喜欢呼喊，是由于少气引起的。这是因为肾气少，导致心气虚而狂。还有种狂病，吃得多，经常看见鬼神，喜欢笑但不发泄出来，是由于大喜引起的。这是说喜伤心神而导致虚狂。还有种狂病是新发的，还没有出现上述症状，应先取肝经的曲泉穴左右动脉放血，如果病情严重的见血即可；过了一会儿还没好，就灸髌骨二十壮。这部分分别论述了狂病的虚实，治疗未发作前先清泄肝木之气，不让病邪波及心神。
《素问·通评虚实论》黄帝问：癫病怎么样？岐伯说：脉搏大而滑，时间久了自己会好。脉搏小坚急，死，无法治疗。黄帝问：癫病的脉象，虚实情况如何？岐伯说：脉虚则可治，脉实则死。这一段总体论述了癫病属于阴气盛。阴盛则阳虚，所以脉搏按之感觉大滑，说明心肝之阳尚未衰竭，有恢复的迹象，所以时间久了自己会好。如果脉搏小坚急，纯阴无阳，就会死，无法治疗。脉虚，邪气也虚；脉实，邪气也实，“实”就是坚急的意思，所以也主死。
《灵枢·癫狂篇》说：癫病初起，先心情不愉快，头重痛，眼睛发红甚至很红，极度疲劳后心烦，观察面色可以诊断。这是说厥气上乘于天气及太阳君火。癫病是阴阳之气，先厥逆于下，后上逆于头顶而发病，应当观察颜面气色。又说：癫病刚发作时，牵引口角、啼哭呼叫、气喘心悸，这是说太阳主开，阳明主阖，厥气上乘，导致开阖功能不清畅而发病。又说：癫病刚发作时，先身体反张僵硬，接着脊背疼痛，这是说厥气逆乱于属寒水的太阳经，以及寒气乘袭地中（人体下部）。又说：治疗癫病的人，经常与患者居住在一起，观察他应该针刺的部位，病发作时观察有过错的经脉进行泻法，将刺出的血放在葫芦壶中，等到病发作时，血独自跳动；如果不跳动，就灸髌骨二十壮。这是说治疗癫病，应当区分天地水火之气来治疗。太阳之火对应日，随天气每天绕地一周，是运动不息的；地水是静止不动的。经常与患者同住，观察病邪在手足哪条经络，方法是将血置于葫芦壶中，发作时气机相感则血动，这是感应天气太阳的运动，应当候察手太阳、手阳明、手太阴经。如果不跳动，说明病陷于地水中，应当候察足太阳、足阳明、足太阴经，更宜灸髌骨二十壮。如果不尽早图谋治疗，病成之后就很难治了。所以《下经》中关于骨癫疾、筋癫疾、脉癫疾，大多说无法治疗。
至于痫证，《素问·奇病论》黄帝问：人生下来就有癫疾病的，病名叫什么，是怎么得的？岐伯回答：病名叫胎病，这是在母腹中时得的，当时母亲受到大惊吓，气向上而不向下，精气并居，所以让孩子发为癫疾。这是论述生下来就患癫痫，是先天所受的疾病。孕妇受惊，精气上逆不下，精与惊气并居而成病，所以叫胎病。然而也有不是从母腹中得来的，比如突然听到惊吓而得的，大概是因为惊则神出舍空，痰涎乘隙而入。但痫证与癫厥不同之处在于，仆倒时口中发出六畜的声音，将醒时吐涎沫而已。更有血迷类似癫证的，妇人月经崩漏过多，血气迷心，或产后恶露上冲，导致语言错乱、神志不宁的，这是血虚神耗。还有心风类似癫证的，精神恍惚，喜怒言语有时错乱，有癫的症状，但不如癫证严重，这些都是痰气致病，不可不辨别。
The Fifty-Ninth Difficulty asks: How can one distinguish between Kuang (mania) and Dian (epilepsy/severe mental disorder)?
Answer: When Kuang disease first manifests, the patient sleeps little and feels no hunger, considers themselves virtuous, intelligent, noble, and arrogant; they laugh without reason, enjoy singing and music, and engage in reckless behavior without ceasing. This is Kuang disease. When Dian disease first manifests, the patient feels unhappy, stares fixedly, and suddenly collapses stiffly; their pulse is vigorous at all three positions (cun, guan, chi) across both yin and yang aspects. This is Dian disease.
Kuang disease belongs to Yang. At onset, Yang qi is excessive and fails to enter Yin, resulting in little sleep. Yang qi converges upward, causing lack of appetite. The attitudes of considering oneself virtuous, intelligent, and noble/arrogant are the mental characteristics of Kuang. Laughing without reason, enjoying singing, and reckless behavior are the physical manifestations of Kuang. Since the disease originates in Yang, and Yang is dynamic, its symptoms represent "excess" (Shi pattern). This corresponds to what was stated in the Twentieth Difficulty: "Double Yang leads to Kuang."
Dian disease belongs to Yin. At onset, the patient feels unhappy, which is the mental characteristic of Dian; staring fixedly and sudden stiff collapse are its physical manifestations. Since the disease originates in Yin, and Yin is static, its symptoms represent "deficiency" (Xu pattern). This corresponds to the Twentieth Difficulty: "Double Yin leads to Dian."
The phrase "pulse vigorous at all three positions across yin and yang" summarizes the above. It means that for Kuang originating in Yang, the Yang pulses at the three positions are vigorous; for Dian originating in Yin, the Yin pulses at the three positions are vigorous.
Commentary: In *Su Wen: Bing Neng Lun*, the Yellow Emperor asked: A person suffers from anger-induced mania. How does this disease arise? Qibo answered: It arises from Yang pathogens. The Emperor asked: How do Yang pathogens cause mania? Qibo said: Human Yang qi, due to sudden frustration and inability to resolve, leads to irritability; this disease is named Yang Jue (Yang Stupor). The Emperor asked: How do we know this? Qibo said: The Yangming meridian pulse is usually palpable; the Taiyang (Giant Yang) and Shaoyang meridians' pulses are usually not palpable. If the non-palpable ones become rapidly palpable, this is the sign. The Emperor asked: How to treat it? Qibo said: Restrict their food intake, and administer a drink made of Sheng Tie Luo (Iron Filings). Sheng Tie Luo acts swiftly to descend Qi. This section generally discusses that Kuang disease belongs to excessive Yang qi. Yang qi should ascend and diffuse; if suppressed, disease occurs. The pulse originates from Taiyang and Shaoyang; where these normally do not move but now move rapidly, and the Yangming pulse, which normally moves, becomes very vigorous, it indicates an impending Kuang attack. One should first restrict diet to weaken Stomach Fire and decline Qi, so Yang movement subsides and the disease heals. If severe, administer Tie Luo Yin to descend Qi, open stagnation, and calm Liver Wood and Heart Fire pathogens.
*Ling Shu: Dian Kuang Pian* states: Mania begins with sadness, forgetfulness, bitter anger, and fear, caused by worry and hunger. This indicates Yin deficiency leading to Yang excess, causing mania. It also states: Early Kuang features little sleep, no hunger, self-aggrandizement, arrogance, cursing day and night; this is Kuang due to Heart Qi Excess. Another form involves startled speech, laughter, singing, and reckless behavior, caused by great fright; this indicates Kidney disease transmitting to the Heart, causing Heart Qi Excess Kuang, as great fright injures the Kidney. Another form involves visual/auditory hallucinations and shouting, caused by Qi Deficiency; this is Kidney Qi deficiency leading to Heart Qi deficiency Kuang. Another form involves polyphagia, seeing spirits, laughing internally, caused by great joy; this indicates Joy injuring the Heart Spirit, leading to Deficient Kuang. For new-onset Kuang before other symptoms appear, bleed the Ququan points on both sides of the Liver meridian; if severe, bleeding suffices. If unhealed after a while, moxa the patella twenty burns. This section differentiates Kuang into Excess and Deficiency, treating early stages by clearing Liver Wood Qi to prevent invasion of the Heart Spirit.
In *Su Wen: Tong Ping Xu Shi Lun*, the Emperor asked: What about Dian disease? Qibo said: If the pulse is large and slippery, it will heal spontaneously over time. If small, firm, and rapid, it is fatal and untreatable. The Emperor asked: Regarding Dian pulse, what of Excess and Deficiency? Qibo said: Deficient pulse is treatable; Excess pulse is fatal. This section generally discusses that Dian disease belongs to excessive Yin qi. Yin excess leads to Yang deficiency. Thus, a large and slippery pulse indicates Heart and Liver Yang have not yet failed and show signs of recovery, hence spontaneous healing. A small, firm, and rapid pulse indicates pure Yin without Yang, hence fatal. A deficient pulse implies deficient pathogen; an Excess pulse implies Excess pathogen ("Excess" meaning firm/rapid), hence also fatal.
*Ling Shu: Dian Kuang Pian* states: Early Dian begins with unhappiness, heavy head pain, red eyes, extreme fatigue followed by vexation; diagnose by observing facial complexion. This indicates Jue Qi ascending to Heaven Qi and Taiyang Jun Fire. Dian involves Yin-Yang Qi, first Jue at the lower body, then ascending to the vertex; observe facial Qi color. It also states: Early Dian involves mouth traction, crying, panting, and palpitations; this indicates Taiyang governs opening, Yangming governs closing; Jue Qi ascends, disrupting opening/closing functions. Another case: Early Dian involves initial rigidity and spinal pain; this indicates Jue Qi reversing in the Cold-Water Taiyang meridian and Cold Qi invading the Earth region (lower body). Treatment involves living with the patient to identify acupoints. Upon attack, observe pathological meridians and apply draining method; place blood in a gourd vessel. If the blood moves during the attack, it reflects the movement of Heaven Qi/Taiyang; observe Hand Taiyang, Hand Yangming, Hand Taiyin. If blood does not move, the disease has sunk into Earth/Water; observe Foot Taiyang, Foot Yangming, Foot Taiyin; moxa the patella twenty burns. Early intervention is crucial; late-stage bone, tendon, or vessel Dian are often untreatable (*Xia Jing*).
Regarding Xian (Epilepsy) syndrome: *Su Wen: Qi Bing Lun* asks: Congenital Dian disease? Name and origin? Qibo answers: Named Tai Bing (Fetal Disease), acquired in utero when the mother suffered great fright. Qi ascended instead of descending, essence and Qi co-resided, causing fetal Dian. This describes congenital epilepsy due to maternal fright, where essence and fright Qi co-reside. However, some cases arise from sudden fright post-birth; fright scatters the Spirit, allowing Phlegm-Drool to invade. Xian differs from Dian/Jue by producing animal-like sounds during collapse and spitting foam upon waking. Blood confusion mimics Dian: excessive menstrual bleeding or postpartum lochia rushing upward confuses the Heart, causing disordered speech and restless spirit due to Blood deficiency and Spirit consumption. Heart Wind mimics Dian: vague spirit, erratic emotions/speech, milder than Dian; all caused by Phlegm-Qi disorders, requiring differentiation.