经水适来适断，或有往来寒热者，先服小柴胡，以去其寒热，后以四物汤和之。薛新甫
治一妇人，耳内或耳后项侧作痛，寒热口苦，月经不调，此肝火气滞而血凝，用小柴胡加山
栀、川芎、丹皮治之，诸病悉退。（诸症皆见在少阳经，故用此汤，此经多气少血，何为不用当归、赤芍、生地）
大全云∶师尼寡妇与室女出嫁愆期者，多因欲心萌而不遂，恹恹成病，乍寒乍热，
久则为劳。又有经闭白淫，痰逆头风，膈气痞闷，面 瘦瘠等证，皆寡妇之病也。（此仓公治欲男子不得之法也）
薛氏曰∶前证若肝脉弦出鱼际，用小柴胡加生地黄送下生地黄丸，久而血虚，佐以四物汤（此妇遍身欲火，
降火凉血，亦是正法。大约寒凉过度，又须治本也）。若兼
怒动肝火而寒热者，佐以加味逍遥散。一妇人因夫经商久不归，发寒热，月经旬日方止，服
降火凉血药，反潮热内热，自汗盗汗，月经频数。余曰∶热汗，气血虚也；经频，肝脾虚也
，用归脾汤、六味丸而愈。
良方云∶妇人伤寒伤风发热，经水适来，昼则安静，暮则谵语，有如疟状，此为热
入血室。治者无犯胃气及上二焦，宜服小柴胡汤（邪入血分，故发在暮，且谵语属胃经者多，恐误犯之。故云然）。
若脉迟身凉，当刺期门穴，下针病患五吸
，停针良久，徐徐出针。凡针期门穴，必泻勿补，肥人二寸，瘦人寸半也。
许学士治一妇病伤寒发寒热，遇夜则如见鬼状，经六七日，忽然昏塞，涎响如引锯，牙
关紧急，暝目不知人，病势危困。许视之曰∶得病之初，曾值月经来否？其家云∶经水方来
，病作而经遂止，得一二日发寒热，昼虽静，夜则有鬼祟，从昨日不省人事。许曰∶此乃热
入血室证。仲景云∶妇人中风发热恶寒，经水适来，昼则明了，暮则谵语，如见鬼状，发作
有时，此名热入血室。医者不晓，以刚剂与之，遂致胸膈不利，涎潮上脘，喘急息高，昏冒
不知人。当先化其痰，后除其热。乃急以一呷散投之，两时顷涎下，得睡省人事。次授以小
柴胡汤加生地黄，三服而热除，不汗而自解矣。（明知热入血室，乃因症而小治也，所谓急则治标，后治其本也）
一妇人患热入血室证，医者不识，用补血调气药治之，数日遂成血结胸。或劝用前药。
许公曰∶小柴胡已迟，不可行也，无已，用期门穴斯可矣。予不能针，请善针者治之，如言
而愈（便不能针，或用桃仁承气合小柴胡亦可）。或问热入血室，何为而成结胸也？许曰∶邪气传入经络，与正气相搏，
上下流行，遇
经水适来适断，邪气乘虚入于血室，血为邪所迫，上入肝经，肝受邪，则谵语而见鬼，复入
膻中，则血结于胸中矣。何以言之？妇人平居，水养木，血养肝，方未受孕，则下行之为月
水；既孕，则中畜之以养胎；及已产，则上壅之以为乳，皆血也。今邪逐血并归于肝经，聚
于膻中，结于乳下，故手触之则痛，非药可及，故当刺期门也。
虞恒德治一少妇，夏月行经，得伤寒似疟，谵语狂乱（凡诊妇人，先问经候有无，此是关窍，凡经行后似疟谵语，
便是热入血室）。诸医皆以伤寒内热，投双解散、
解毒汤服之，大汗如雨，反如风状；次以牛黄丸、金石之药，愈投愈剧。一日延虞诊视，脉
弦而大。虞思伤寒内热狂乱，六阳俱病，岂不口干舌黑，况脉不数，病体扪之，或热或静，
其腹急痛（病根在腹急痛）。意必有内伤在前，伤寒在后，今伤寒得汗虽已，内伤则尚存故也。因细问之，患
者曰∶正行经时，因饮食后多汗，用冷水抹身，因得此证。方知冷水外闭其汗，内阻其血，
邪热入室，经血未尽，血得邪热，乍静乍乱，寒热谵语，掉眩类风，须得玉烛散下之而愈。
下后谵语已定，次以四物小柴胡汤，调理五日，热退身凉，患遂瘳。
衍义云∶一妇人温病已十二日，诊之其脉六七至而涩，寸稍大，尺稍小，发寒热，
颊赤口干不了了，耳聋，问之病，数日经水乃行，此属少阳热入血室也。若治不对病，则必
死。乃按其证，与小柴胡汤，服之二日，又与小柴胡汤加官桂、干姜，一日寒热遂止（以脉六七至，明知是热，涩则知
其为有瘀血，寸大尺小上焦有热，此亦兼阳明胃腑病，以颊赤口干不了了，而用姜桂，亦人所难，须慎之）。又
云∶脐下急痛，又与抵当丸微利，脐下痛痊，身渐凉，脉渐匀，尚不了了，乃复与小柴胡汤
；次日但胸中热躁，口鼻干，又少与调胃承气汤，不得利；次日心下痛，又与大陷胸汤半服
，利三行；次日虚烦不宁，时妄有所见，复狂言。虽知其尚有燥屎，以其极虚，不敢攻之，
遂与竹叶汤，去其烦热。其夜大便自通，至晚两次，中有燥屎数枚，而狂言虚烦尽解，但咳
嗽唾，此肺虚也。若不治恐成肺痿，遂与小柴胡汤，去人参、大枣、生姜，加干姜五味子
汤，一日咳减，二日而病悉愈。以上皆用仲景方。（五味、干姜，以治咳嗽，以未成痿，故可加，否则误矣）
薛立斋治一妇人，怀抱素郁，感冒经行谵语，服发散之剂不应。用寒凉降火，前证益甚
，更加月经不止，肚腹作痛，呕吐不食，痰涎自出，此脾胃虚寒。用香砂六君子，脾胃渐健
，诸证渐退，又用归脾汤而痊愈。（以感冒故发散，以谵语故清凉，然云前症益甚，而复用香砂归脾，人所难信，其意
重在呕吐痰涎自出上耳。然终有疑，当以脉评，学人不可以是而造次也，慎之）
[Background Information]
Book: Ji Yin Gang Mu (Compendium of Gynecology)
Author: Wu Zhiwang
Dynasty: Ming
Chapter: Discussion on Alternating Chills and Fever / Discussion on Heat Entering the Blood Chamber
Category: Comprehensive
[Translation]
When menstruation has just started or just ended, and there are symptoms of alternating chills and fever, first administer Chaihu Tang (Minor Bupleurum Decoction) to eliminate the chills and fever, and subsequently harmonize with Siwu Tang (Four Substances Decoction).
Xue Xinpu treated a woman who suffered from pain in the ears, behind the ears, or on the side of the neck, accompanied by alternating chills and fever, bitter taste in the mouth, and irregular menstruation. This was due to Liver Fire hyperactivity and Qi stagnation causing blood coagulation. He used Chaihu Tang (Minor Bupleurum Decoction) added with Gardeniae Fructus (Zhizi), Ligusticum Rhizome (Chuanxiong), and Moutan Cortex (Danpi), resulting in the resolution of all symptoms. (Since all symptoms manifest in the Shaoyang channel, this formula is used; as this channel has abundant Qi but scarce Blood, why not use Angelicae Sinensis Radix (Danggui), Red Peony Root (Chishao), and Rehmanniae Radix (Shengdi)?)
The *Daquan* records: Nuns, widows, and virgins who marry late often suffer from illness due to aroused desires that remain unfulfilled, leading to depression and melancholy. Symptoms include intermittent chills and fever, which may develop into consumptive disease (Lao) over time. Other conditions include amenorrhea, leukorrhea (Baiyin), rebellious Phlegm, wind-headache, chest oppression and fullness, and emaciation with sallow complexion; these are diseases specific to widows. (This refers to the method of Cang Gong for treating "frustrated desire for men".)
Mr. Xue stated: If the aforementioned condition presents with a wiry Liver pulse extending beyond the Thenar eminence (Yuji), administer Chaihu Tang (Minor Bupleurum Decoction) added with Rehmanniae Radix (Shengdi), taken with Shengdi Wan (Rehmannia Pill). If blood deficiency persists over time, assist with Siwu Tang (Four Substances Decoction). (This addresses the symptom of generalized internal heat/fire in women, using cooling and blood-nourishing methods, which is correct. However, excessive use of cold-cooling herbs requires addressing the root cause.) If accompanied by alternating chills and fever triggered by anger stirring up Liver Fire, assist with Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder).
A woman developed alternating chills and fever because her husband had been away on business for a long time. Her menstruation lasted ten days before stopping. After taking herbs to clear fire and cool blood, she instead experienced tidal fever, internal heat, spontaneous sweating, and night sweats, along with frequent menstruation. I said: Hot sweat indicates deficiency of Qi and Blood; frequent menstruation indicates deficiency of the Liver and Spleen. She was cured using Guipi Tang (Restore the Spleen Decoction) and Liuwei Wan (Six-Ingredient Pill with Rehmannia).
The *Liangfang* records: When a woman suffers from Cold Damage (Shanghan) or Wind Strike (Shangfeng) with fever, and menstruation happens to commence, she remains quiet during the day but experiences delirium at dusk, resembling malaria. This is called Heat Entering the Blood Chamber (Re Ru Xue Shi). Treatment should avoid damaging Stomach Qi and the Upper and Middle Jiao; it is appropriate to administer Chaihu Tang (Minor Bupleurum Decoction). (Pathogenic factors enter the Blood level, hence onset at dusk; delirium often relates to the Stomach channel, so caution is advised against damaging Stomach Qi and the Upper/Middle Jiao.) If the pulse is slow and the body is cool, puncture Qimen (LR14). Insert the needle while the patient takes five breaths, retain the needle for a considerable time, then withdraw slowly. When puncturing Qimen (LR14), always use the reducing method, never reinforcing. For obese individuals, insert two cun; for thin individuals, insert one and a half cun.
Academician Xu treated a woman suffering from Cold Damage with alternating chills and fever. At night, she appeared to see ghosts. After six or seven days, she suddenly became comatose and obstructed, with rattling phlegm sounds like sawing, locked jaw, eyes closed, and unconsciousness. The condition was critical. Academician Xu examined her and asked, "At the beginning of the illness, did your menstruation occur?" The family replied, "Menstruation had just started, but stopped when the illness began. One or two days later, chills and fever appeared. Although quiet during the day, she sees spirits at night. She has been unconscious since yesterday." Xu said, "This is the syndrome of Heat Entering the Blood Chamber. Zhang Zhongjing stated: 'In women with Wind Strike presenting fever and aversion to cold, if menstruation happens to commence, they are lucid during the day but delirious at dusk, appearing to see ghosts, with episodic onset. This is named Heat Entering the Blood Chamber.' Physicians who do not understand this may administer harsh/drying agents, leading to chest and diaphragm discomfort, upward surging of phlegm to the epigastrium, wheezing with high-pitched breathing, and coma/unconsciousness. One must first resolve the Phlegm, then clear the Heat. Urgently administer Yi Ya San (One-Sip Powder). After two hours, the phlegm descended, and she fell asleep and regained consciousness. Subsequently, administer Chaihu Tang (Minor Bupleurum Decoction) added with Rehmanniae Radix (Shengdi). After three doses, the fever resolved, and she recovered without sweating. (Knowing it is Heat Entering the Blood Chamber, yet treating mildly first due to acute symptoms, following the principle of 'treating the branch in emergencies, then the root'.)"
A woman suffered from Heat Entering the Blood Chamber, but the physician failed to recognize it, treating her with blood-nourishing and Qi-regulating herbs. After several days, this developed into Blood Stasis Chest Syndrome (Xue Jie Xiong). Someone suggested using the previous formula. Mr. Xu said, "Using Chaihu Tang (Minor Bupleurum Decoction) is now too late and ineffective. As a last resort, puncture Qimen (LR14)." I cannot perform acupuncture, so I requested a skilled acupuncturist to treat her. Following this advice, she recovered. (If acupuncture is not possible, Taoren Chengqi Tang combined with Chaihu Tang may also be used.)
Someone asked why Heat Entering the Blood Chamber leads to Chest Syndrome (Jie Xiong). Mr. Xu said, "Pathogenic factors enter the collaterals and contend with healthy Qi, circulating up and down. When menstruation has just started or ended, pathogenic factors take advantage of the deficiency to enter the Blood Chamber. The Blood is forced by the pathogens to move upward into the Liver channel. When the Liver is affected, delirium and hallucinations occur. If it re-enters the Danzhong (Chest Center), blood coagulates in the chest. Why? Normally, Kidney Water nourishes Liver Wood, and Blood nourishes the Liver. Before pregnancy, Blood descends as menstruation; during pregnancy, it is stored centrally to nourish the fetus; after childbirth, it ascends to become milk. All are forms of Blood. Now, pathogens chase the Blood back to the Liver channel, gathering in the Danzhong and condensing below the breasts. Thus, touch causes pain, and herbs cannot reach it; therefore, puncturing Qimen (LR14) is necessary."
Yu Hengde treated a young woman who, during summer menstruation, contracted Cold Damage resembling malaria, with delirium and mania. (When diagnosing women, first inquire about menstruation; this is key. Post-menstrual malaria-like symptoms and delirium indicate Heat Entering the Blood Chamber.) Other physicians diagnosed it as Cold Damage with internal heat and administered Shuangjie San (Double Resolution Powder) and Jiedu Tang (Detoxification Decoction). This caused profuse sweating like rain, making her resemble a stroke victim. Next, Niuhuang Wan (Calculus Bovis Pill) and mineral drugs were used, worsening the condition. Yu was invited to diagnose. The pulse was wiry and large. Yu reasoned: Cold Damage with internal heat and mania involves all Yang channels; would she not have dry mouth and black tongue? Moreover, the pulse is not rapid, and upon palpation, the body temperature fluctuates between hot and quiet, with urgent abdominal pain (the root lies in urgent abdominal pain). He suspected prior internal injury followed by Cold Damage. Although Cold Damage was resolved by sweating, the internal injury remained. Upon detailed inquiry, the patient stated that during menstruation, after eating and sweating heavily, she wiped herself with cold water, causing this condition. Thus, cold water externally closed the pores and internally blocked the Blood. Pathogenic heat entered the interior. With incomplete menstrual blood, the Blood combined with pathogenic heat, causing alternating calmness and madness, chills/fever, delirium, tremors/dizziness resembling wind-stroke. It required Yuzhu San (Jade Candle Powder) to purge and cure.
After purging, the delirium stabilized. Subsequently, Siwu Tang (Four Substances Decoction) combined with Chaihu Tang (Minor Bupleurum Decoction) was used for five days of regulation. The fever subsided, the body cooled, and the illness improved.
The *Yanyi* records: A woman suffered from Warm Disease for twelve days. Her pulse was rapid (6-7 beats per breath) and choppy. The Cune (inch) position was slightly large, and the Cun (foot) position slightly small. She had alternating chills and fever, red cheeks, persistent dry mouth, and deafness. Inquiry revealed menstruation started a few days later. This belongs to Shaoyang Heat Entering the Blood Chamber. If treatment is incorrect, death is certain. Based on the syndrome, Chaihu Tang (Minor Bupleurum Decoction) was given. After two days, Chaihu Tang (Minor Bupleurum Decoction) added with Cinnamomi Cortex (Guizhi/Guigui) and Zingiberis Rhizoma (Ganjiang) was given. After one day, chills and fever stopped. (Pulse rate of 6-7 indicates Heat; choppy pulse indicates Blood stasis; large Cune/small Cun indicates Heat in the Upper Jiao. This also involves the Yangming Stomach organ. Using Ginger and Cinnamon for red cheeks and dry mouth is difficult for others, requiring caution.) It further states: Urgent pain below the umbilicus was treated with Didang Wan (Didang Pill) to mildly purge. The pain resolved, body cooled, pulse normalized, but discomfort persisted. Chaihu Tang (Minor Bupleurum Decoction) was repeated. The next day, only chest heat/restlessness and dry mouth/nose remained. A small dose of Tiaowei Chengqi Tang (Regulate the Stomach Purge Decoction) was given, but no stool passed. The next day, epigastric pain occurred, and half a dose of Daxianxiong Tang (Great Hypochondriac Accumulation Decoction) was given, resulting in three bowel movements. The next day, deficiency irritability and restlessness appeared, with occasional visual hallucinations and rambling speech. Although dry feces were known to exist, due to extreme deficiency, aggressive purging was avoided. Instead, Zhuye Tang (Bamboo Leaf Decoction) was given to remove irritability and heat. That night, bowel movement occurred naturally. By evening, two movements passed, containing several pieces of dry feces. Rambling speech and deficiency irritability completely resolved, leaving only cough and sputum, indicating Lung deficiency. Without treatment, Lung Flaccidity (Fei Wei) might develop. Thus, Chaihu Tang (Minor Bupleurum Decoction) was given, removing Ginseng, Jujube, and Ginger, adding Zingiberis Rhizoma (Ganjiang) and Schisandrae Fructus (Wuweizi) Decoction. Cough decreased in one day, and the illness resolved in two days. All above formulas are from Zhang Zhongjing. (Schisandra and Ginger treat cough; since Lung Flaccidity has not formed, addition is acceptable; otherwise, it is an error.)
Xue Lizhai treated a woman with chronic emotional depression who contracted a cold and developed delirium during menstruation. Dispersing agents were ineffective. Cold-cooling and fire-clearing herbs worsened the condition, leading to continuous menstruation, abdominal pain, vomiting, anorexia, and spontaneous salivation/phlegm. This indicated Spleen-Stomach deficiency-cold. Xiangsha Liujunzi Tang (Aucklandia and Amomum Six Gentlemen Decoction) was used. Spleen-Stomach function gradually strengthened, symptoms receded, and Guipi Tang (Restore the Spleen Decoction) completed the cure. (Dispersing agents were used for the cold; cooling herbs for delirium. However, the worsening of symptoms followed by the use of warming Spleen-Stomach herbs is hard to believe. The emphasis seems to be on vomiting and spontaneous phlegm. Nevertheless, doubt remains; pulse evaluation is essential. Students should not act rashly based on this alone. Be cautious.)