经义
不得卧而息有音者，是阳明之逆也。足三阳者下行，今逆而上行，故息有音也。阳明者，胃脉也。胃者，
六腑之海，其气亦下行，阳明逆不得从其道，故不得卧也。下经曰∶胃不和则卧不安，此之谓也。（《素问》）
帝曰∶病不得卧者，何气使然？岐伯曰∶卫气不得入于阴，常留于阳。留于阳则阳气满，阳气满则阳跷
盛；不得入于阴则阴气虚，故目不瞑矣。○帝曰∶老人之不夜瞑者，何气使然？少壮之人不昼瞑者，何气使然？
岐伯曰∶壮者之气血盛，肌肉滑，气道通，营卫之行不失其常，故昼精而夜瞑。老者之气血衰，肌肉枯，气道
涩，五脏之气相搏，营气衰少，卫气内伐，故昼不精，夜不瞑。（《灵枢》）
哲言
不寐，夜常长寤也。阴虚清清不寐，痰扰神昏不寐。不瞑，夜目不闭也。卫气不入于阴，则目不瞑；阳
邪入于阴，烦躁不得瞑。不得卧，身不得仆也。水气卧则喘，喘故不得卧。卧不安，
反侧不得安卧也。（《医阶辨证》）
不寐之故，大约有五∶一曰气虚，一曰阴虚，一曰痰滞，一曰水停，一曰胃不和。大端虽五，然虚实寒热，
互有不齐，神而明之，存乎其人耳。（《医宗必读》）
不寐虽病有不一，然惟知邪、正二字则尽之矣。盖寐本乎阴，神其主也，神安则寐，不安则不寐。其所以
不安者，一由邪气之扰，一由营气之不足耳。有邪者多实证，无邪者多虚证。凡如伤寒、伤风、疟疾之不寐者，
此言外邪深入之扰也。如痰、如火、如寒气水气、如饮食忿怒之不寐者，此皆内邪滞逆之扰也。此外则凡思虑
劳倦，惊恐忧疑，及别无所累而常多不寐者，总属真阴精血之不足，阴阳不交，而神有不安其室耳。知此二者，
则知所以治矣。○饮浓茶则不寐，心有事亦不寐，以心气之被伐也。盖心藏神，为阳气之宅也，卫主气，司阳
气之化也。凡卫气入阴则静，静则寐，正以阳有所归，故神安而寐也。而浓茶以阴寒之性，大制元阳，阳为阴
抑，则神索不安，是以不寐也。又心为事扰则神动，神动则不静，是以不寐也。故欲求寐者，当养阴中之阳，
及去静中之动，则得之矣。（张景岳）
卫气行阳则寤，行阴则寐，故寐属阴而寤属阳也。不寐由阴气之虚，不寤由阳气之困，故不寐当养阴，而
不寤当养阳也。若年高之人，昼反多卧，而夜反不寐者，此其阴阳反背，营卫之行，失其常度，不可治也。（沈朗仲）
《内经》概言卫气不得入于阴而不得卧，尚未能尽其心肾神交入阴之至理也。盖心主血而藏神，若元阴
不足，则不能生血，血少则神无所倚矣。夫人之神，寤则栖心，寐则归肾，故寐者，心神归于肾舍也。心虚则
神不能归舍于肾，故不能成寐；肾虚则不能藏纳心神于舍，故寐而不能沉，并不能久。是以壮年肾阴强盛，则
睡熟而长；老年阴气衰弱，则睡微而短。且有形之阴水既亏，则无形之相火流灼，以致神魂散越，睡卧不安。
故不寐、健
忘两证，虽似心病，实由于肾虚也。（《冯氏锦囊》）
热气伏于里，则喜睡；热气浮于上，烦扰阳气，故不得眠。亦有心火不降而不眠者，此即阳不交于阴耳。（成无己）
人卧则血归于肝，气归于肾。肾开窍于耳，故寐而能闻。肝在味为酸，故寤多口酸。然其所以归肾、归肝
者，皆胃为之传送，故胃不和则卧不安。胆热则肝不受血，心肾不交则肾不纳气，不寐之病所由起也。○肾虚
则气趋于肾，故但欲寐为肾病。肝虚则血恋于肝，故嗜卧为肝病。（《医参》）
补编
不寐一证，责在营卫之偏胜，阴阳之离合。医家于卫气不得入阴之旨而细心体会之，则治内虚不寐，何
难之有？夫卫气昼行于阳二十五度而主寤，夜行于阴二十五度而主寐。平人夜卧之时，呵欠先之者，以阳引而
升，阴引而降，阴阳升降，然后渐入睡乡。若肝肾阴亏，阳浮于上，营卫不交，神明之地扰乱不安，万虑纷纭，
却之不去，由是上者颧赤，中则脘胀，下则便数，坐以待旦，欲求其目瞑也得乎？又常见初睡之时，忽然跳跃，
似惊而醒，医以为心虚胆怯，孰知不然。何也？缘阳升阴降，阴阳交合，有造化自然之妙。奈营弱卫强，初入
之时，契合浅而脱离快，升者复升，降者复降，形体之间，自不觉如有所坠而复寤矣。明乎此，则治阴虚不寐
者，必须壮水之主，以镇阳光。盖水壮则火熄，心静则神藏，乙癸同源，而藏魂之脏，亦无相火妄动之患。倘
其人本体阳虚，虚阳浮越而不寐者，又宜归脾、八味，阴阳相济，益火之原。盖阳生则阴长，逆治则火藏而心
神自安其位耳。至于外感时疫而不寐者，乃邪气之耗扰；内伤停滞而不寐者，乃胃中之乖戾。更有喘咳不休，
诸痛不止，疟痢不愈而不寐者，无非本证之累及，但治其受困之由，而无有不酣睡者矣。虽然，治外因者易，
治内因者难。先君子于阴不维阳不寐一证，专用纯甘之味，加入犀角、羚羊、龟版、虎睛、琥珀、龙齿、珍珠，以物之
灵而引人之灵，两相感召，神有凭根据，诚法中之善者也。彼逍遥散之舒肝，补心丹之安神，温胆汤之化痰，未
为不善，是在用之者为何如耳！（汪蕴谷）
不寐故非一种，总是阳不交阴所致。若因外邪而不寐者，如伤寒、疟疾等证暴发，营卫窒塞，升降失常，
愁楚呻吟，日夜难安，当速去其邪，攘外即所以安内也。若因里病而不寐者，或焦烦过度而离宫内燃，从补心
丹及枣仁汤法。或忧劳愤郁而耗损心脾，宗养心汤及归脾汤法。或精不凝神而龙雷震荡，当壮水之主，合静以
制动法。或肝血无藏而魂摇神漾，有咸补甘缓法。胃病则阳跷穴满，有半夏秫米汤。胆热则口苦心烦，有温胆
汤及桑叶、丹皮、山栀轻清少阳法。营气伤极，人参、人乳并行。阳浮不摄，七味、八味可选。余如因惊宜镇，
因怒宜疏。饮食、痰火为实，新产、病后为虚。（《临证指南》）
不寐有由真阴亏损，孤阳漂浮者，此水亏火旺，火主乎动，气不得安。盖肺为上窍，居阳分至高，肾为下
窍，居阴分最下。肺主气，肾藏气，旦则上浮于肺而动，夜则下入于肾而静。仙家所谓子藏母胎，母隐子宫，
水中金也。若水亏火旺，肺金畏火，不纳肾水，阴阳俱动，故不寐。治宜六味丸加知、柏之类。有由胃不和者，
盖胃气本下行，而寐亦从阴而主下，今胃气上逆，则壅于肺而息有音，不得从其阴降之道，故亦不寐。药宜橘
红、甘草、石斛、茯苓、半夏、神曲之类。（沈金鳌）
妇人肥盛，多郁不得眠者，从郁结痰火治。大抵胆气宜静，浊气痰火扰之则不眠，宜用温胆汤、猪胆汁、
炒半夏曲，加柴胡、枣仁，立效。○平人不得卧，多起于劳心思虑，喜怒惊恐。举世用补心安神药鲜效。曷知
五志不伸，往往生痰聚饮，饮聚于胆，则胆寒肝热，故魂不归肝而不得卧。《内经》用半夏汤涤其痰饮，阴阳
通，其卧立至。（张路玉）
凡病后、产后不得眠者，此皆血气亏虚，心脾二脏不足。
虽有痰火，不可过攻，当以补养为君，而略佐清痰火之药。其有不因病后而不寐者，虽属痰火有余，而处治亦
必佐以养血补虚之药，方为妥当。（徐东皋）
凡治病者，服药即得寐，此得效之征也。正以邪居神室，卧必不安，若药已对证，则一匕入咽，群邪顿退，
盗贼甫去，民即得安。此其治乱之机，判于顷刻，药之效否，即此可知。其有误治妄投者，反以从乱，反以助
虐，必致烦恼懊 ，更增不快。知者见几，当以此预知矣。（张景岳）
选案
一人患阴虚火旺，彻夜不眠者两月，食废形削。方用人参、枣仁、茯神、远志、生地、当归、五味子、麦
冬，佐以琥珀、辰砂、金银器，百剂而瘳。此证心经虽有火，幸未灼肺，多服补阴收敛之剂，水火自然升降矣。（缪仲淳）
宛平王中堂，患一奇证，每寐即梦持重搬运，甚觉困乏而醒，睡去，其梦如故，一夜数十次。医用参、
归、枣仁、茯神、远志养血安神之药，愈服愈甚。诊脉两寸洪大有力，两关洪大兼弦，两尺洪弦无力，知为药
误。盖寐者，心神藏纳于肾，乃水火既济之时。心犹人也，肾犹舍也，今心阴不足，肾火独亢，乃遂上炎之性，
而失下交之象矣。盖心中之水，真水也；肾中之火，真火也。水火互藏其根，故心能下交，肾能上摄。今心肾
已成不交之象，复补其心阳，愈增其上炎之势，焉能使阳会于阴，元神凝聚于内乎？乃以重剂八味汤，加牛膝、
五味子，用灯心、莲子作引，数服而愈。（冯楚瞻）
一妇不眠两月，眩晕胁痛，咳嗽呕吐。医谓气血两虚，服补药不效。诊左关脉弦数有力，右关弦滑而濡。
断为肝火上逆，脾有湿痰。盖脾为心之子，脾有邪则心不能舍于脾，谓之母不舍子，故不眠。脾中有痰，故作
晕亦作呕；肝火上逆，故作咳作呕亦作晕。方用半夏、陈皮、苍术、煨姜，燥脾中之湿痰；黄连、香
附、竹茹、白芍，平上逆之肝气。吐痰碗许而愈。（吴天士）
四明董生，病患神志不安，每卧觉身在床而神魂离体，惊悸无寐。医作心病治，不效。予诊之曰∶此肝病
也。肝虚，邪气袭之。肝藏魂者也，游魂为变。平人肝不受邪，卧则魂归于肝，神安而得寐。今肝有邪，魂不
得归，是以飞扬若离体也。董生欣然曰∶前此未之闻，虽未服药，已觉沉 去体矣，愿求良治。处方用珠母为
君，龙齿佐之，珠母入肝，龙齿与肝相类。龙齿、虎睛，人以为镇心之用，殊不知龙齿安魂，虎晴定魄，各从
其类也。盖东方苍龙，木也，属肝而藏魂；西方白虎，金也，属肺而藏魄。龙能变化，故魂游而不定；虎能专
静，故魄止而有守。治魄不守者宜虎睛，治魂飞扬者宜龙齿。服药一月而痊。（《赤水玄珠》）
有人卧则觉身外有身。盖人卧则魂归于肝，此由肝虚邪袭，魂不归舍，名曰离魂。用人参、龙齿、茯神各
一钱，煎汤，调朱砂末一钱，睡时服。三夜后，真者气爽，假者化矣。（《同寿录》）
附欠
肾为欠。○胃足阳明之脉，是动则病振寒，善数伸欠。○二阳一阴发病，主惊骇，善噫善欠。○疟之始作也，
善伸数欠。（《素问》）
帝曰∶人之欠者，何气使焉？岐伯曰∶卫气昼日行于阳，夜半则行于阴。阴者主夜，夜主卧。阳者主上，
阴者主下，故阴气积于下，阳气未尽，阳引而上，阴引而下，阴阳相引，故数欠。（《灵枢》）
肾病，面黑，善恐数欠。（《难经》）
夫中寒家善欠。（《金匮》）
气乏，故欠伸引之。（《医学入门》）
《内经》虽以欠隶诸阳明，然必由少阴经气下郁，不能上走阳明，胃气因之不舒，而频呼数欠，以泄其气，
舒其经。若少阴气不下郁，胃气虽泄，则但呵而不欠也。（张路玉）
阳引而上，阴引而下，寤后之欠然也。若将卧之欠，则必阴引而上，阳引而下矣。何也？肝上而肾居下也。（《医参》）
【经文释义】
无法入睡且呼吸有声的，是阳明经气逆乱所致。足部三阳经的气血本应下行，如今反而上行，所以呼吸会有声音。阳明经，即胃脉。胃，是六腑的大海，其气也应当下行。如果阳明经气逆乱，不能顺着正常的通道运行，就会导致无法入睡。《下经》说：“胃不和则卧不安”，说的就是这个道理。（出自《素问》）
黄帝问道：患失眠症的人，是什么气机导致的？岐伯回答：卫气不能进入阴分，常常停留在阳分。停留在阳分，则阳气偏盛；阳气偏盛，则阳跷脉充盛；不能进入阴分，则阴气虚弱，所以眼睛睁着无法闭目睡眠。○黄帝又问：老年人夜间难以入眠，是什么气机导致的？青壮年人白天不嗜睡，又是什么原因？岐伯回答：壮年人气血旺盛，肌肉滑利，气道通畅，营气和卫气的运行不失常态，所以白天精神饱满，夜晚能安然入睡。老年人气血衰退，肌肉枯槁，气道涩滞，五脏之气相互搏结，营气衰少，卫气内扰，所以白天精神不振，夜晚难以入眠。（出自《灵枢》）
【哲人言论】
不寐，是指整夜常醒的状态。阴虚导致的神志清冷而不寐，痰浊扰乱心神导致的神昏不寐。不瞑，是指夜间眼睛无法闭合。卫气不入于阴分，则眼睛无法闭合；阳邪侵入阴分，导致烦躁而无法入眠。不得卧，是指身体无法安卧。水气病者，躺下则喘息，因为喘息所以无法安卧。卧不安，是指翻来覆去无法安稳躺卧。（出自《医阶辨证》）
不寐的原因，大约有以下五种：一是气虚，二是阴虚，三是痰滞，四是水停，五是胃不和。虽然大体分为这五类，但虚实寒热往往错综复杂，能否灵活掌握并明察秋毫，全在于医者个人的悟性。（出自《医宗必读》）
不寐虽然病症不一，但只要懂得“邪”与“正”这两个字就能概括全部了。因为睡眠根本在于阴，神是主宰，神安则能睡，神不安则不寐。之所以神不安，一方面是由邪气干扰，另一方面是由于营气不足。有邪气的多为实证，无邪气的多为虚证。像伤寒、伤风、疟疾等引起的不寐，这是外邪深入体内的干扰。像痰、火、寒气、水气、饮食停滞或愤怒情绪引起的不寐，这些都是内邪阻滞逆乱的干扰。除此之外，凡是因思虑过度、劳累疲倦、惊恐忧疑，以及没有其他负担却经常不寐的，总归属于真阴精血的不足，阴阳不能相交，导致神没有安宁的居所。明白了这两点，就知道如何治疗了。○喝浓茶会导致不寐，心里有事也会导致不寐，这是因为心气被耗损。盖心藏神，是阳气的宅舍；卫主气，主管阳气的化生。凡是卫气进入阴分则安静，安静则能入睡，正是因为阳气有所归宿，所以神安而能睡。而浓茶具有阴寒之性，极大地抑制元阳，阳气被阴寒抑制，则神索求不安，因此导致不寐。另外，心事干扰心脏则神动，神动则不静，因此导致不寐。所以想要求得睡眠，应当滋养阴中之阳，去除静中之动，就能达到目的了。（张景岳）
卫气行于阳分则清醒，行于阴分则睡眠，所以睡眠属阴，清醒属阳。不寐是由于阴气虚，不醒（嗜睡）是由于阳气困顿，所以不寐应当养阴，而不醒应当养阳。如果是老年人，白天反而多睡，晚上反而不寐，这是阴阳背道而驰，营卫运行失去了常态，这种病很难治愈。（沈朗仲）
《内经》大概只说了卫气不能进入阴分而导致无法入睡，还没有完全讲尽心肾之神相交入阴的深奥道理。盖心主血而藏神，如果元阴不足，就不能生血，血少则神无所依托。人的神，清醒时栖居于心，睡眠时归于肾，所以睡眠，就是心神归于肾的居所。心虚则神不能回归肾舍，所以不能成眠；肾虚则不能收纳心神于舍，所以即使睡了也不能深沉，更不能持久。因此壮年时肾阴强盛，则睡得熟且时间长；老年时阴气衰弱，则睡得浅且时间短。而且有形之阴水既然亏损，则无形之相火就会流窜灼烧，导致神魂散乱，睡卧不安。所以不寐、健忘两证，虽然看似心病，实际上是由于肾虚引起的。（《冯氏锦囊》）
热气伏藏在体内，则喜欢睡觉；热气浮越于上部，烦扰阳气，所以不得安眠。也有因为心火不下降而导致不眠的，这就是阳不交于阴。（成无己）
人躺下时，血液归于肝，气归于肾。肾开窍于耳，所以睡眠中能听见声音。肝在五味中对应酸味，所以醒来时常觉得口酸。然而气之所以归肾、血之所以归肝，都是因为胃在其中传送，所以胃不和则卧不安。胆热则肝不受血，心肾不交则肾不纳气，这是不寐病产生的原因。○肾虚则气趋向于肾，所以只想睡觉是肾病。肝虚则血恋滞于肝，所以嗜睡是肝病。（《医参》）
【补编】
不寐这一证候，责任在于营卫的偏胜和阴阳的离合。医家如果对卫气不能进入阴分的宗旨细心体会，那么治疗内虚引起的不寐，有什么难的？卫气白天在阳分行进二十五周次而主清醒，夜晚在阴分行进二十五周次而主睡眠。普通人夜晚躺下时，先打哈欠，是因为阳气引而上升，阴气引而下降，阴阳升降协调，然后逐渐进入梦乡。如果肝肾阴亏，阳气浮越于上，营卫不交，神明之地受到扰乱不安，万般思绪纷纭，驱赶不去，由此上面出现颧骨发红，中间出现脘腹胀满，下面出现小便频数，坐着等待天亮，想要求得闭上眼睛入睡怎么可能呢？又常见刚要入睡时，忽然跳跃，似受惊而醒，医生认为是心虚胆怯，其实不然。为什么呢？因为阳升阴降，阴阳交合，有着造化自然的妙用。无奈营弱卫强，刚进入睡眠时，契合浅薄而脱离迅速，上升的又上升，下降的又下降，形体之间，不知不觉就像有所坠落而再次清醒了。明白这个道理，那么治疗阴虚不寐者，必须壮水之主（滋补肾阴），以镇摄阳光（浮越之阳）。因为水壮则火熄，心静则神藏，乙癸同源（肝肾同源），而藏魂之脏（肝），也没有相火妄动的祸患。倘若其人本体阳虚，虚阳浮越而不寐的，又适宜用归脾汤、八味丸，使阴阳相互济助，益火之源（温补肾阳）。因为阳生则阴长，逆向治疗（针对阳虚浮越）则火藏而心神自然安守其位。至于外感时疫而不寐的，是邪气的耗损干扰；内伤停滞而不寐的，是胃中的乖戾之气。更有喘咳不停、诸痛不止、疟痢不愈而导致不寐的，无非是本证牵连波及，只要治疗其受困的原因，就没有不能酣睡的。虽然，治疗外因容易，治疗内因难。先父对于阴不维阳（阴虚不能制约阳气）的不寐一证，专门使用纯甘的药物，加入犀角、羚羊角、龟板、虎睛、琥珀、龙齿、珍珠，利用物的灵性来感召人的灵性，两者相互感应，神有所凭依根据，这确实是法度中的良方。那些逍遥散疏肝，补心丹安神，温胆汤化痰，并非不好，关键在于使用者如何运用罢了！（汪蕴谷）
不寐原因并非一种，总是阳不交阴所导致。如果因外邪而不寐的，如伤寒、疟疾等证暴发，营卫窒塞，升降失常，愁苦呻吟，日夜难安，应当迅速祛除邪气，攘除外邪即是安内。如果因里病而不寐的，或因焦躁烦恼过度导致离宫（心）内燃，采用补心丹及枣仁汤的方法。或因忧劳愤郁导致耗损心脾，遵循养心汤及归脾汤的方法。或因精不凝神导致龙雷之火震荡，应当壮水之主，配合静以制动的法则。或因肝血无藏导致魂摇神漾，采用咸补甘缓的方法。胃病则阳跷穴满盛，可用半夏秫米汤。胆热则口苦心烦，可用温胆汤及桑叶、丹皮、山栀轻清少阳的方法。营气损伤至极，人参、人乳并行。阳浮不摄，可选用七味丸、八味丸。其余如因惊吓宜镇惊，因愤怒宜疏泄。饮食、痰火为实证，新产、病后为虚证。（《临证指南》）
不寐有由真阴亏损，孤阳漂浮的，这是水亏火旺，火主乎动，气不得安宁。盖肺为上窍，居阳分最高处，肾为下窍，居阴分最深处。肺主气，肾藏气，早晨则上浮于肺而动，夜晚则下入于肾而静。道家所谓子藏母胎，母隐子宫，即水中金。如果水亏火旺，肺金畏惧火势，不接纳肾水，阴阳俱动，所以不寐。治疗适宜用六味丸加知母、黄柏之类。有由胃不和引起的，盖胃气本应下行，而睡眠也从阴而主下，如今胃气上逆，则壅塞于肺而呼吸有声，不能顺从其阴降之道，所以也不寐。药物适宜用橘红、甘草、石斛、茯苓、半夏、神曲之类。（沈金鳌）
妇人肥胖体盛，多因忧郁不得睡眠的，从郁结痰火论治。大抵胆气宜静，浊气痰火扰乱它则不眠，适宜用温胆汤、猪胆汁、炒半夏曲，加柴胡、枣仁，立见疗效。○普通人不得卧，多起于劳心思虑，喜怒惊恐。举世使用补心安神药很少见效。怎知五志不伸，往往生痰聚饮，饮聚于胆，则胆寒肝热，所以魂不归肝而不得卧。《内经》用半夏汤涤除其痰饮，阴阳通调，其卧立至。（张路玉）
凡是病后、产后不得眠的，这都是血气亏虚，心脾二脏不足。虽然有痰火，不可过分攻伐，当以补养为主，略微佐以清痰火的药物。那些不因生病后而不寐的，虽然属于痰火有余，但处理时也必定佐以养血补虚的药物，才算妥当。（徐东皋）
凡治病，服药后即能入睡，这是得效的迹象。正因为邪气占据神室，卧必不安，如果药已对症，则一匕入口，群邪顿退，盗贼刚去，百姓即得安宁。这是治乱的关键，判断于顷刻之间，药效与否，由此可知。如果有误治妄投的，反而助长混乱，反而助长暴虐，必然导致烦恼懊恼，更增不快。明智的人见到征兆，应当以此预先知晓。（张景岳）
[Scriptural Interpretation]
Inability to sleep accompanied by noisy breathing is caused by the rebellion of Yangming channel Qi. The three Yang channels of the foot normally descend; now they rebel and ascend, hence the noisy breathing. The Yangming channel is the Stomach pulse. The Stomach is the sea of the six fu organs, and its Qi also should descend. If Yangming Qi rebels and cannot follow its normal pathway, it leads to inability to sleep. The *Xia Jing* (Lower Classic) states: "When the Stomach is not harmonious, sleep is unsettled," which refers to this situation. (From *Su Wen*)
The Yellow Emperor asked: What Qi causes the disease of inability to sleep? Qibo answered: Wei Qi (Defensive Qi) cannot enter Yin and often remains in Yang. Remaining in Yang makes Yang Qi full; when Yang Qi is full, the Yang Qiao vessel becomes excessive. Inability to enter Yin makes Yin Qi deficient, thus the eyes remain open and cannot close for sleep. ○ The Yellow Emperor further asked: What Qi causes the elderly to be unable to sleep at night? And what Qi causes the young and vigorous to not sleep during the day? Qibo answered: In vigorous people, Qi and Blood are abundant, muscles are smooth, airways are unobstructed, and the movement of Ying Qi (Nutritive Qi) and Wei Qi follows its normal pattern, so they are energetic during the day and sleep soundly at night. In the elderly, Qi and Blood decline, muscles wither, airways become stagnant, the Qi of the five zang organs clashes, Ying Qi becomes scarce, and Wei Qi attacks internally, so they lack energy during the day and cannot sleep at night. (From *Ling Shu*)
[Philosophical Discourse]
Insomnia (Bu Mei) refers to a state of being awake throughout the night. Insomnia due to Yin deficiency involves a clear but restless spirit; insomnia due to phlegm disturbance involves mental confusion. Non-closure of eyes (Bu Ming) refers to the eyes remaining open at night. When Wei Qi does not enter Yin, the eyes cannot close; when Yang pathogenic factors enter Yin, irritability prevents sleep. Inability to lie down (Bu De Wo) means the body cannot rest. Water qi disease causes panting when lying down, hence the inability to lie down. Unsettled sleep (Wo Bu An) refers to tossing and turning without comfort. (From *Yi Jie Bian Zheng*)
The causes of insomnia are roughly fivefold: one is Qi deficiency, one is Yin deficiency, one is Phlegm stagnation, one is Water retention, and one is Stomach disharmony. Although these are the main categories, deficiency/excess and cold/heat are often intermixed. Whether one can apply wisdom and understand the nuances depends on the individual practitioner. (From *Yi Zong Bi Du*)
Although insomnia presents differently, it can be fully understood through the concepts of "Pathogen" (Xie) and "Righteous Qi" (Zheng). Sleep fundamentally relies on Yin, and the Spirit (Shen) is the master. When the Spirit is at peace, there is sleep; when disturbed, there is no sleep. The reason for disturbance is either interference by pathogenic factors or insufficiency of Ying Qi. Cases with pathogens are mostly excess syndromes; cases without pathogens are mostly deficiency syndromes. For instance, insomnia caused by Cold Damage (Shang Han), Wind Strike (Shang Feng), or Malaria is due to the disturbance of deep-penetrating external pathogens. Insomnia caused by phlegm, fire, cold qi, water qi, dietary stagnation, or anger is due to the disturbance of internal pathogenic stagnation and rebellion. Aside from these, insomnia caused by overthinking, fatigue, fright, worry, or occurring without other burdens generally belongs to the insufficiency of True Yin Essence and Blood, where Yin and Yang do not interact, leaving the Spirit without a peaceful abode. Understanding these two aspects reveals how to treat them. ○ Drinking strong tea causes insomnia, as does having worldly concerns, because both deplete Heart Qi. The Heart stores the Spirit and is the residence of Yang Qi; Wei Qi governs Qi and manages the transformation of Yang Qi. When Wei Qi enters Yin, there is stillness, and stillness leads to sleep, precisely because Yang has a return, allowing the Spirit to be at peace. Strong tea, with its yin-cold nature, severely suppresses Primordial Yang. When Yang is suppressed by Yin, the Spirit seeks unrest, causing insomnia. Furthermore, worldly matters disturb the Heart, moving the Spirit; moved spirits are not still, causing insomnia. Therefore, to seek sleep, one must nourish the Yang within Yin and remove the movement within stillness. (Zhang Jingyue)
When Wei Qi travels in Yang, one is awake; when it travels in Yin, one sleeps. Thus, sleep belongs to Yin and wakefulness to Yang. Insomnia is due to deficiency of Yin Qi, while inability to wake (hypersomnia) is due to entrapment of Yang Qi. Therefore, insomnia should be treated by nourishing Yin, and hypersomnia by nourishing Yang. If an elderly person sleeps more during the day but cannot sleep at night, their Yin and Yang are reversed, and the movement of Ying and Wei Qi has lost its normal measure; such conditions are difficult to cure. (Shen Langzhong)
The *Nei Jing* generally states that Wei Qi's inability to enter Yin causes insomnia, but it does not exhaustively explain the profound principle of the Heart and Kidney Spirits interacting and entering Yin. The Heart governs Blood and stores the Spirit. If Primordial Yin is insufficient, it cannot generate Blood; if Blood is scant, the Spirit has no support. The human Spirit resides in the Heart when awake and returns to the Kidney when sleeping. Thus, sleep is the return of the Heart Spirit to the Kidney's residence. If the Heart is deficient, the Spirit cannot return to the Kidney, leading to insomnia; if the Kidney is deficient, it cannot store the Heart Spirit, leading to light and short sleep. Therefore, in youth, strong Kidney Yin results in deep, long sleep; in old age, weak Yin results in shallow, short sleep. Moreover, when tangible Yin Water is depleted, intangible Ministerial Fire flares and burns, scattering the Soul and Body Spirit, causing restless sleep. Thus, although insomnia and forgetfulness seem like Heart diseases, they are actually caused by Kidney deficiency. (*Feng Shi Jin Nang*)
Heat qi lurking inside leads to drowsiness; heat qi floating upward disturbs Yang Qi, causing insomnia. There are also cases of insomnia due to Heart Fire failing to descend, which is essentially Yang failing to interact with Yin. (Cheng Wuji)
When lying down, blood returns to the Liver, and Qi returns to the Kidney. The Kidney opens into the ears, so one can hear while sleeping. The Liver corresponds to the sour taste, so one often tastes sour upon waking. However, the reason Qi returns to the Kidney and Blood to the Liver is mediated by the Stomach; thus, Stomach disharmony leads to unsettled sleep. Gallbladder heat prevents the Liver from receiving Blood; Heart-Kidney non-interaction prevents the Kidney from grasping Qi; these are the origins of insomnia. ○ Kidney deficiency causes Qi to trend toward the Kidney, leading to desire to sleep (Kidney disease). Liver deficiency causes Blood to linger in the Liver, leading to lethargy (Liver disease). (*Yi Can*)
[Supplement]
Insomnia is attributed to the predominance of Ying and Wei Qi and the separation of Yin and Yang. If physicians carefully contemplate the principle of Wei Qi failing to enter Yin, treating internal deficiency insomnia will pose no difficulty. Wei Qi travels 25 cycles in Yang during the day (governing wakefulness) and 25 cycles in Yin at night (governing sleep). When healthy people lie down at night, yawning precedes sleep because Yang draws upward and Yin draws downward; only after Yin-Yang ascending and descending do they gradually enter sleep. If Liver and Kidney Yin are deficient, Yang floats upward, Ying and Wei do not interact, and the realm of Spirit is disturbed, with endless thoughts arising and refusing to leave. This manifests as red malar flush above, epigastric distension in the middle, and frequent urination below. Sitting until dawn, how can one hope to close their eyes? Often, upon initially falling asleep, one suddenly jumps up, startled awake. Physicians attribute this to Heart deficiency and Gallbladder timidity, but this is incorrect. Why? Because Yang ascends and Yin descends, and their interaction has the natural wonder of creation. However, with weak Ying and strong Wei, the initial connection is shallow and breaks quickly; the ascending rises again, the descending falls again, and the body feels as if falling, leading to wakefulness. Understanding this, treating Yin-deficiency insomnia requires strengthening the source of Water (nourishing Kidney Yin) to suppress Yang Light. When Water is strong, Fire extinguishes; when the Heart is quiet, the Spirit hides. Since Liver and Kidney share the same source, the organ storing the Soul (Liver) avoids ministerial fire hyperactivity. If the constitution is Yang deficient with floating false Yang causing insomnia, Guipi Tang (Spleen-Restoring Decoction) or Bawei Wan (Eight-Ingredient Pill) should be used to mutually assist Yin and Yang and benefit the source of Fire. When Yang generates, Yin grows; treating inversely [for floating Yang] allows Fire to hide and the Heart Spirit to settle. As for insomnia due to external epidemic pathogens, it is exhaustion and disturbance by pathogens; insomnia due to internal injury and stagnation is rebellion in the Stomach. Insomnia accompanied by incessant coughing/wheezing, unceasing pain, or persistent malaria/dysentery is merely a complication of the primary disease; treating the cause of distress ensures sound sleep. Although treating external causes is easy, treating internal causes is difficult. My late father, for insomnia where Yin fails to anchor Yang, exclusively used pure sweet substances, adding Rhinoceros Horn (Xi Jiao), Antelope Horn (Ling Yang Jiao), Tortoise Shell (Gui Ban), Tiger Eye (Hu Jing), Amber (Hu Po), Dragon Tooth (Long Chi), and Pearl (Zhen Zhu), using spiritual substances to resonate with human spirit, providing a foundation for the Spirit. This is indeed an excellent method. Xiaoyao San (Free and Easy Wanderer Powder) for soothing the Liver, Buxin Dan (Heart-Nourishing Pill) for calming the Spirit, and Wendan Tang (Gallbladder-Warming Decoction) for resolving phlegm are not bad methods; it depends on how the practitioner uses them. (Wang Yungu)
Insomnia is not of a single type; it is always caused by Yang failing to interact with Yin. If caused by external pathogens, such as acute Shang Han or Malaria, where Ying and Wei are blocked and ascending/descending functions fail, causing suffering and groaning day and night, one must rapidly expel the pathogen; expelling the exterior is the way to pacify the interior. If caused by interior diseases: excessive anxiety burning the Heart (Li Gong) calls for Buxin Dan and Zaoren Tang; worry/fatigue damaging Heart and Spleen calls for Yangxin Tang and Guipi Tang; essence failing to consolidate spirit with Long-Lei fire shaking calls for strengthening the source of Water and using stillness to control movement; Liver Blood failing to store causing Soul trembling calls for salty tonification and sweet relaxation. Stomach disease fills the Yang Qiao acupoint, calling for Banxia Shumi Tang. Gallbladder heat causing bitter taste and irritability calls for Wendan Tang plus Sang Ye, Mu Dan Pi, and Shan Zhi to lightly clear Shaoyang. Extreme damage to Ying Qi calls for Ginseng and Human Milk. Floating Yang failing to grasp calls for Qiwei or Bawei pills. Others: fright requires sedation, anger requires dispersal. Diet and Phlegm-Fire are excess; postpartum and post-illness are deficiency. (*Lin Zheng Zhi Nan*)
Insomnia caused by True Yin depletion and floating solitary Yang involves Water deficiency and Fire prosperity. Fire is active, preventing Qi from settling. The Lung is the upper aperture, residing highest in Yang; the Kidney is the lower aperture, residing lowest in Yin. The Lung governs Qi, the Kidney stores Qi; in the morning, Qi floats to the Lung and moves; at night, it enters the Kidney and rests. Daoists call this "Son hidden in Mother's womb, Mother hidden in Uterus," i.e., Metal in Water. If Water is deficient and Fire prosperous, Lung Metal fears Fire and does not accept Kidney Water; Yin and Yang both move, causing insomnia. Treatment suits Liuwei Wan (Six-Ingredient Pill) plus Zhimu and Huangbai. Insomnia caused by Stomach disharmony occurs because Stomach Qi normally descends, and sleep also follows Yin and descends. Now, rebellious Stomach Qi obstructs the Lung, causing noisy breathing, and cannot follow the Yin-descending pathway, causing insomnia. Medicines suit Juhong, Gancao, Shihu, Fuling, Banxia, and Shenqu. (Shen Jin'ao)
Obese women with much depression and insomnia should be treated for depressed Phlegm-Fire. Generally, Gallbladder Qi prefers stillness; turbid Qi and Phlegm-Fire disturbing it cause insomnia. Wendan Tang, Pig Bile, and fried Banxia Qu, added with Chai Hu and Suan Zao Ren, produce immediate effects. ○ Normal people unable to lie down often start from mental labor and worry, joy, anger, fright. The world rarely finds effect with Heart-nourishing and Spirit-calming medicines. How does one know that unexpressed Five Emotions often generate Phlegm and Fluid retention; when Fluids gather in the Gallbladder, the Gallbladder becomes cold and the Liver hot, so the Soul does not return to the Liver, causing insomnia. The *Nei Jing* uses Banxia Tang to wash away Phlegm-Fluids; once Yin and Yang connect, sleep arrives immediately. (Zhang Luyu)
Insomnia after illness or childbirth is due to Blood and Qi deficiency and insufficiency of the Heart and Spleen. Even if Phlegm-Fire exists, do not attack excessively; tonification should be primary, slightly assisted by clearing Phlegm-Fire. For those not ill before but experiencing insomnia, even if Phlegm-Fire is excess, treatment must assist with Blood-nourishing and deficiency-tonifying herbs to be appropriate. (Xu Donggao)
In treating diseases, falling asleep immediately after taking medicine is a sign of efficacy. Pathogens occupy the Spirit chamber, causing unrest in sleep. If the medicine matches the syndrome, one dose enters the throat, pathogens retreat, thieves depart, and the people find peace. The key to order and chaos is judged in an instant; efficacy is known here. Misdiagnosis and wrong prescriptions instead aid chaos and cruelty, causing vexation and discomfort. Wise people see the signs and predict this in advance. (Zhang Jingyue)