Library

The disciple asked, "Women are primarily governed by blood. Physicians often speak of the 'Sea of Blood' (Xue Hai). Can this concept be pointed to a specific anatomical location?"

Chen Xiuyuan replied, "The Sea of Blood in the human body is the Uterus (Bao Gong). It resides outside the Bladder and serves as its chamber. The *Classic* states: 'The Chong Mai (Penetrating Vessel) and Ren Mai (Conception Vessel) both originate from within the Bao Zhong (center of the uterus).' This indicates that both men and women possess this Sea of Blood.

However, in men, it is transported and circulated; in women, it is retained and accumulated. Transported and circulated substances do not accumulate to excess, thus Yang Qi corresponds to the sun's cycle, manifesting once daily (referring to the generation and discharge of essence). Retained and accumulated substances fill up before being released, thus Yin Blood corresponds to the moon's cycle, descending once monthly. This is the common root of Tian Gui (substances promoting reproductive maturity) for both men and women. In the field of Gynecology, special emphasis is placed on menstruation. The *Classic* states: 'When the Ren Mai is unobstructed and the Tai Chong Mai is vigorous, menstruation arrives on time, enabling conception.' By 'on time,' it means descending after a thirty-day cycle, mirroring the moon's fullness followed by waning. Descending without missing its timing is why it is called 'Yue Xin' (Monthly Trust/Menstruation).

The disciple Gao Zi asked, "True masters of gynecology are rare; we must strive to revitalize this field. I have brought dozens of gynecological texts and ask you to select those suitable for teaching. After reading them all, I had great insights and said: The ancients named menstruation 'Yue Xin' (Monthly Trust). This naming is not only precise but also encompasses the presence, absence, quantity, speed, and all principles of treatment within the character 'Xin' (Trust/Regular Timing). In the Five Elements, Earth corresponds to the virtue of 'Xin' (Trust/Fidelity). The Spleen is Yin Earth, and the Stomach is Yang Earth; both belong to 'Xin'. 'Xin' implies descending on schedule without deviation. Although it is said that the Heart generates blood and the Liver stores blood, and the Chong, Ren, and Du vessels are all called the Sea of Blood, the source of menstruation, their overall control lies solely in the Spleen and Stomach. When the Spleen and Stomach are harmonious, blood is naturally generated, because blood is produced from the essence of food and water. If the source of essence and blood varies in timing, quantity, or presence, it is called 'irregular.' Irregularity constitutes a breach of 'trust.' The *Classic* states: 'Excessive Earth becomes high and mounded.' 'Fu' means high; 'Dun' means thick or dense. If it is both high and thick, one should remove the excess using Ping Wei San (Calm the Stomach Powder) augmented with Da Huang (Rhubarb), Bai Shao (White Peony Root), Zhi Shi (Immature Bitter Orange), and Tao Ren (Peach Seed). The *Classic* further states: 'Insufficient Earth becomes low and depressed.' 'Bei' means low; 'Jian' means sunken or pit-like. If it is low and sunken, one should tonify using Liu Jun Zi Tang (Six Gentlemen Decoction) augmented with Xiong Diao (Ligusticum), Dang Gui (Angelica Sinensis), Chai Hu (Bupleurum), Bai Shao, and Gui Pi Tang (Restore the Spleen Decoction). This analyzes irregular menstruation based on deficiency and excess.

Others analyze it based on Yin-Yang imbalance. Xu Shuwei said: Women's diseases often involve menstruation that is suddenly heavy or light, early or late, accompanied by intermittent pain. Physicians generally call this a menstrual disorder without distinguishing whether Yin overcomes Yang or Yang overcomes Yin, hence medications often yield little effect. If Yin Qi overcomes Yang Qi, the Uterus becomes cold, and blood fails to circulate. As the *Classic* says, 'When heaven is cold and earth frozen, water congeals into ice,' causing menstruation to be suddenly scanty and delayed (or completely absent). If Yang Qi overcomes Yin, blood and Qi scatter and overflow. As the *Classic* says, 'In summer heat and hot earth, menstrual water boils,' causing menstruation to be suddenly heavy and early (or occurring multiple times a month, or continuous metrorrhagia). One must 'distinguish Yin and Yang, harmonize Qi and Blood, prevent discord, and aim for balance.' This is Shuwei's general discussion on the Way of Yin and Yang. However, I use the terms 'Yin' and 'Yang' specifically to refer to the Spleen and Stomach. The Spleen is Tai Yin damp-earth; without the regulating dry-Qi of Yang Ming, Cold-Damp prevails, Yin dominates alone, and the Yin path is constantly deficient—this aligns with the *Nei Jing*'s concept of 'Bei Jian' (Low and Depressed). The Stomach is Yang Ming dry-earth; without the regulating moisture of Tai Yin, Dry-Heat prevails, Yang dominates alone, and the Yang path is constantly excessive—this aligns with the *Nei Jing*'s concept of 'Dun Fu' (High and Mounded). Regarding prescription, Si Wu Tang (Four Substances Decoction) added with Xiang Fu (Cyperus Rhizome), Fu Shen (Poria with Hostwood), and Zhi Gan Cao (Honey-fried Licorice) serves as the main formula. For Yin excess, add Gan Jiang (Dried Ginger), Gui Zhi (Cinnamon Twig), Fu Zi (Aconite Root), Wu Zhu Yu (Evodia Fruit), Tao Ren, and Hong Hua (Safflower). For Yang excess, add Zhi Mu (Anemarrhena), Bai (Phellodendron), Qin (Scutellaria), Lian (Coptis), and Dong (Ophiopogon). Though these methods are plain and simple, they should not be discarded. To seek the profound subtleties, Wen Jing Tang (Warm the Menses Decoction) from the *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet) is effective regardless of Yin/Yang, deficiency/excess, obstruction/metrorrhagia, or age, if used skillfully. Not only would modern gynecologists be astonished by this, but even commentators on the *Jin Gui* over centuries may lack the insight to explain it or keep it as a secret. Now that Chen Xiuyuan is old, I must choose worthy disciples to transmit this knowledge. Upon transmitting, I warn: The *Ling Shu* records the Yellow Emperor telling Lei Gong, 'This was forbidden by our predecessors, transmitted only through the oath of cutting arms and drinking blood.' Formulas beyond ordinary comprehension should not be lightly shared, lest the Qi leak and lose its spirit. One must choose scholars of great learning and upright character before teaching them.

The disciple asked, "Menstruation occurring once a month is normal; early, late, obstructed, or patent are pathological. Occasionally, there are cases not related to disease. May I hear your explanation?"

I said, "In the world, there are norms and variations. During the expected time of menstruation, if blood does not descend but instead appears as hematemesis (vomiting blood), epistaxis (nosebleed), or bleeding from eyes/ears, this is called 'Dao Jing' (Reverse Menstruation). If it occurs once every three months, it is called 'Ju Jing' (Residing Menstruation). Once a year, 'Bi Nian' (Avoiding Year). Never occurring but still conceiving, 'An Jing' (Hidden Menstruation). Continuing to menstruate monthly during pregnancy until delivery, 'Tai Sheng' (Fetal Abundance), commonly known as 'Gou Tai' (Dirt Menstruation). Heavy bleeding several months into pregnancy without miscarriage, 'Lou Tai' (Leaking Fetus). Although abnormal, suffering from these does not necessarily harm health. People treat these anomalies as normal, and the Central Earth (Spleen/Stomach) loses its principle of 'Trust,' like a person lacking integrity who relies on deceit to succeed—a gentleman does not do this. Generally, women suffering from these conditions have eccentric temperaments.

The disciple asked, "Having heard about irregular menstruation, I now wish to hear about methods to regulate it."

I said, "Opinions on regulating menstruation vary. Xiao Shenzhang argues that removing disease must precede regulating menstruation. I record Li's argument detailing etiology and treatment, and Fang's argument, synthesizing both, which deeply resonates with me. I record them fully below.

Li said: Women's menstrual circulation allows for conception if no other symptoms exist. If accompanied by tidal fever or abdominal pain, severe cases involve coughing, sweating, vomiting, or diarrhea. Tidal fever consumes blood; sweating, coughing, and vomiting cause Qi to ascend; diarrhea diverts fluids downward; pain causes accumulation centrally. Therefore, one must first remove the disease before nourishing blood and regulating menstruation. Tidal fever and pain are particularly common. Blood stasis accumulating in bone marrow becomes 'Gu Zheng' (Bone-steaming consumption); blood stasis fighting with newly generated blood causes pain; blood deficiency failing to nourish the body causes internal steaming heat; blood deficiency with fire in the uterine collaterals, combined with phlegm-Qi, food stagnation, or cold, causes pain. All these diseases obstruct regular menstruation; one must remove the disease first.

Fang said: Women's menstrual disorders include irregularity and obstruction. Among these, some have pain, some have fever, dividing them into four categories. Detailed analysis shows: Irregularity includes advancing (early) and retarding (late); advancing indicates Heat, retarding indicates Deficiency. Obstruction includes blood deficiency and blood stasis; stasis requires breaking blood, deficiency requires tonifying. Pain includes constant pain and pre/post-menstrual pain; constant and pre-menstrual pain indicate blood accumulation, post-menstrual pain indicates blood deficiency. Fever includes constant fever and menstrual fever; constant fever indicates blood deficiency with accumulation, menstrual fever indicates blood deficiency with Heat. These four divide into eight. Human Qi and Blood flow continuously; sudden worry, thought, or anger causes stagnation. Pre/post-menstrual exposure to cold drinks or chill causes lochia retention. These cause irregularity, obstruction, pain, and fever. Generally, Qi moves so Blood moves; Qi stops so Blood stops. Thus, treating blood disorders prioritizes moving Qi, e.g., Xiang Fu. Heat promotes flow; Cold causes coagulation. Thus, treating blood disorders uses warm herbs as assistants, e.g., Rou Gui (Cinnamon Bark).

Xiao Shenzhang said: Some women have disease first, leading to irregular menstruation; others have irregular menstruation first, leading to disease. If disease precedes irregularity, treat the disease first; once cured, menstruation regulates itself. If irregularity precedes disease, regulate menstruation first; once regulated, disease resolves. Li's theory is essential but partial; I supplement it. Fang's detailed classification captures the general principles of regulating menstruation.

The disciple asked, "You emphasize the Spleen and Stomach regarding menstruation as 'Monthly Trust,' extracting the essence rather than sticking to the literal words of the *Nei Jing*. From which section did you derive this?"

I said, "The *Shi Jing* summarizes with 'Think No Evil'; the *Li Ji* covers it with 'Be Reverent.' My theory derives from the section 'Diseases of Er Yang (Stomach/Large Intestine) originate in Heart and Spleen.' I record the original text and various commentaries for study. The *Nei Jing* states: 'Diseases of Er Yang originating in Heart and Spleen involve hidden difficulties; women will not menstruate. If it transmits to Feng Xiao (Wind Emaciation) or Xi Ben (Gasping Accumulation), it is fatal and untreatable.' Ma Yuantai commented: Er Yang refers to the Foot Yangming Stomach Meridian. As the official of granaries, it accepts food and water. Why can it not accept? This originates from Heart and Spleen. Because women have hidden distress, depression in the Heart prevents blood generation, and blood fails to nourish the Spleen. Initially, the Stomach accepts food, but the Spleen cannot transform it, eventually leading to inability to accept. Thus, Stomach disease originates in Heart and Spleen. Consequently, food and water decrease, failing to generate subtle essence, blood vessels wither, and menstruation fails to arrive. I propose Gui Pi Tang heavily augmented with Lu Rong (Deer Antler) and Mai Men Dong (Ophiopogon), taken for over twenty doses. Wu Shuqing commented: Interpret 'hidden difficulty' as emotional constraint. Hidden feelings cause Qi stagnation; stagnant Qi prevents Heart Qi opening and Spleen Qi transforming, reducing food intake and failing to generate Qi/Blood for the Sea of Blood. Empty Sea of Blood results in amenorrhea. I propose Gui Pi Tang plus Shao Yao and Chai Hu. 'Feng Xiao' refers to fever and emaciation (Stomach governs muscles); I propose Gui Pi Tang plus Dan Pi, Zhi Zi, Di Gu Pi, and Shao Yao. 'Xi Ben' refers to gasping upward (Stomach Qi rebelling); I use Mai Men Dong Tang from *Jin Gui*. Without Stomach Qi, death ensues. This section discusses the origin of menstrual blood.

The disciple asked, "Amenorrhea in women may result from household worries, childbirth, or nursing. Why do unmarried girls also suffer from irregularities?"

I said: "Unmarried girls suffering from this fare worse than married women, often dying. Unmarried girls are whole beings with vigorous Qi and Blood; they should not be obstructed. Amenorrhea here indicates either empty Sea of Blood or reversed meridians. For empty Sea of Blood, use Dang Gui Bu Xue Tang (Tanggui Tonifies the Blood Decoction) plus Mai Dong and Bai Shao (5 qian each), Zhi Gan Cao (2 qian). For extreme deficiency, add Fu Zi (1 qian). Untreated, this leads to internal heat, coughing, skin resembling fish scales, hair loss, and weakness. For reversed meridians, use Mai Men Dong Tang and Shao Yao Gan Cao Tang from *Jin Gui*, plus Niu Xi and Qian Cao, combined with Si Wu Ju Gu Yi Lu Ru Wan. Untreated, this leads to hematemesis, epistaxis, coughing, bone-steaming, and consumptive disease. If Liver Fire is blazing with left hypochondriac stabbing pain and neck scrofula, assist with Xiao Yao San plus Gua Lou, Chuan Bei Mu, Sheng Mu Li, and Qing Pi. If the Liver pulse is wiry reaching the Cunkou and Yuji area, medication alone may fail; proper combination cures it, or use Jia Wei Xiao Yao San. If always cold, poor appetite, and abdominal distension, assist with Liu Jun Zi Tang plus Gan Jiang; Gui Pi Tang and Ba Zhen Tang can be used interchangeably. However, I have a deeper method. Recalling the Xin Chou year of Qianlong, a 22-year-old girl from the Huang family in Zhuzifang initially had amenorrhea. Blood-moving drugs failed. She developed persistent diarrhea, poor appetite, and emaciation. Si Shen Wan and Ba Wei Wan worsened the diarrhea, occurring multiple times from dawn till morning, with blood in stool. I prescribed Huang Tu Tang (Yellow Earth Decoction) from *Jin Gui*, substitiling Chi Shi Zhi for Huang Tu and Gan Jiang for Fu Zi, adding Sheng Lu Rong (5 qian per dose). Intent: stop diarrhea and bloody stool first, then regulate menstruation. After eight doses, diarrhea persisted, but menstruation started. After five more doses, diarrhea and blood stopped. Finally, Liu Jun Zi Tang plus Gan Jiang completed the cure. This shows Lu Rong enters the Chong, Ren, and Du vessels, greatly tonifying blood, unmatched by ordinary herbs. Also, Yu Jiayan's *Yu Yi Cao* records Yang Jideng's daughter with amenorrhea for over a year, fever, poor appetite, emaciation, and sweating, becoming consumptive. Doctors mistook sweating for deficiency and gave Ren Shen and Bai Zhu, drying the blood further. I observed sweat like steam from a steamer and said: 'The treatable aspect here is the sweating.' Since menstrual blood is internally blocked, it exits via the skin, as sweat is also blood. Without sweat and blood flow, the skin dries and death occurs. Use bitter drugs to astringe blood, entering inward to connect to the Chong Mai, reducing heat, starting menstruation, and stopping bleeding—not achievable by tonics. Thus, Long Hui Wan was given three times daily. After a month, slight menstruation occurred, sweat/heat reduced. Reduce to once daily. Another month later, heavy menstruation lasted five days, and all diseases resolved. These two cases represent deficiency and excess contrast; students should infer from one instance.

The disciple asked, "Gynecological books offer one formula per disease, sometimes several. Their number exceeds men's medicine. This book selects only nineteen formulas for regulating menstruation. Is this too brief?"

I said: "The *Nei Jing* has only twelve formulas; *Shang Han Lun* has 113; *Jin Gui* has 243. These can be called formulas. Post-Tang valid formulas are few; most are just collections of herbs, not true formulas. Gynecological formulas are even more superficial, losing the intent of *Shen Nong Ben Cao Jing* and Zhang Zhongjing's formulation principles. Superficial formulas are for superficial doctors and patients; if ineffective, there is no complaint, or illness fades with time. I ignore them. You are thoughtful scholars. Confucians save people with unique insight, which may startle custom. To save widely, one must respect custom. Medicine is no different! I select commonly used formulas carefully. Si Wu Tang is shallow; I add Xiang Fu and Fu Shen (2 qian each) as assistants, referencing Tie Weng Dao Ren's Jiao Gan Wan (Interacting Pill, utilizing invisible Qi transformation). I add Zhi Gan Cao (4 qian) as sovereign, referencing Zhongjing's Mai Mai Tong Jing Tang (Restore Pulse Decoction, utilizing uninterrupted blood transport). This transforms the shallow into miraculous. Only those who read *Nei Jing*, *Ben Cao Jing*, and Zhongjing's works will believe me. There are also modification patterns: Early menstruation adds Qin, Lian, Zhi, Bai; Late menstruation adds Jiang, Gui, Ai Ye. Excess adds Chen Pi, Zhi Shi; Deficiency adds Ren Shen, Bai Zhu. Severe excess obstruction adds Da Huang, Zhi Shi, Tao Ren, Niu Xi, assisted by Di Dang Tang and Tao Ren Cheng Qi Tang. Severe deficiency withering adds Ren Shen, Bai Zhu, Lu Rong, Niu Xi, plus Ren Shen Yang Rong Tang. Abdominal pain refusing pressure during menstruation adds Yan Hu Suo, Mu Xiang; abdominal pain after menstruation adds Ren Shen, Bai Zhu, Gan Jiang. Amenorrhea with reverse flow causing hematemesis/epistaxis adds Niu Xi, Ze Lan, Jiu Zhi, Tong Bian (Child's Urine). If chronic abdominal mass/fullness, remove Di Huang, add Zhi Shi, Ban Xia. Purple color indicates Wind, add Jing Jie, Fang Feng, Bai Zhi; Black indicates severe Heat, add Qin, Lian, Dan Pi, Di Gu Pi; Pale white indicates Deficiency mixed with Phlegm/Water, add Ren Shen, Fu Ling, Chen Pi, Ban Xia; Color like smoke/dust or roof-leak water combines Er Chen Tang plus Fang Feng, Qin Jiao, Cang Zhu; Like bean juice adds Qin, Lian; Yellow/turbid indicates Damp-Phlegm; Clots/sheets unchanged indicate Qi Stagnation, add Yuan Hu, Zhi Shi, Chen Pi. Purple-black color is mostly Heat, sometimes Cold; examine pulse and symptoms. Additionally, for chills, fever, headache: with sweat add Gui Zhi, Sheng Jiang, Da Zao; without sweat add Ma Huang, Xi Xin. See Hai Zang's Liu He Tang for details. Other formulas like Gui Pi and Xiao Yao, while not comparable to *Nei Jing*'s Si Wu Ju Gu Yi Lu Ru Wan, are far superior to Yi Mu Sheng Jin Dan and Xun Shun Wan!"