门人问曰∶妇人以血为主，医者辄云血海，可以实指其所在乎？
陈修园曰∶人身之血海，胞也。居膀胱之外，而为膀胱之室。《经》云∶冲脉任脉皆起于胞中，是男女皆有此血海。
但男则运而行之，女则停而止之。营运者无积而不满，故阳气应日而一举；停止者有积而始满，故阴血应月而一下；此
男女天癸之总根也。而妇人一科，专以月事为主。《经》云∶“任脉通，太冲脉盛，月事以时下，故能有子。”盖时者，
满三旬之期而一下，以象月盈则亏，下之不失其期，故名月信。
门人高子问曰∶女科中好手甚少，不可不大为之振作。因执女科书数十种，属余择而授之。余遍阅大有悟曰∶古人
以月经名为月信，不止命名确切，而月事之有无、多少、迟速，及一切治疗之原委，无不包括于“信”字之中。夫五行
之土，犹五常之信也。脾为阴土，胃为阳土，而皆属信；信则以时而下，不愆其期。虽曰心生血，肝藏血，冲任督三脉
俱为血海，为月信之原，而其统主则惟脾胃，脾胃和则血自生，谓血生于水谷之精气也。若精血之来，前后、多少、有
无不一，谓之不调，不调则为失信矣。《经》云∶土太过则敦阜。阜者，高也；敦者，浓也；既高而又浓，则令除去，
宜用平胃散加大黄、白芍药、枳实、桃仁之类。《经》又云∶土不及则卑监。卑者，下也；监者，陷也，坑也。既下而
又陷坑，则令培补，宜六君子汤加芎、归、柴、芍及归脾汤之类，此言经水不调以虚实分之也。
又有以阴阳偏胜分之者。许叔微云∶妇人病多是月经乍多、乍少，或前、或后，时发疼痛，医者一例呼为经病，不
辨阴胜阳，阳胜阴，所以服药少效。盖阴气胜阳气，则胞寒气冷，血不营运，《经》所谓天寒地冻，水凝成冰，故令乍
少，而在月后；（或断绝不行。）若阳气胜阴，则血气散溢，《经》所谓夏暑地热，经水沸腾，故令乍多，而在月前。（或
一月数下，或崩漏不止。）当“别其阴阳，调其气血，使不相乖，以平为期”。此叔微统论阴阳之道也。而余则以“阴阳”
二字，专指脾胃而言。盖脾者，太阴之湿土也，不得阳明燥气以调之，则寒湿盛；而阴独胜，阴道常虚，即《内经》“卑
监”之旨也。胃者，阳明之燥土也，不得太阴之湿气以调之，则燥热盛；而阳独胜，阳道常实，即《内经》“敦阜”之
旨也。至于用方，以四物汤加香附、茯神、炙草为主，阴胜加干姜、桂、附、吴萸及桃仁、红花之类，阳胜加知、柏、
芩、连、门冬之类，平平浅浅中，亦不可废。若求其所以然之妙，《金匮》温经汤一方，无论阴阳、虚实、闭塞、崩漏、
老少，善用之无不应手取效。此不特今之习女科者闻之吐舌，即数百年来注《金匮》之家，或识见不到而不能言，或珍
为枕秘而不肯言。今修园老矣！不得不择人而传之，但既传之而又嘱之曰∶《灵枢经》载黄帝谓雷公曰∶此先师之所禁，
割臂歃血之盟也。凡思议不可及之方，若轻以示人，则气泄而不神，必择大学问之人，知其居心长浓者，而后授之。
门人问曰∶女人之经，一月一行，其常也；或先或后，或通或塞，其病也；间或有不关于病者，愿闻其说。
曰∶天下事有常而即有变。妇人当月事之期，其血不下，只见吐血、衄血、或眼耳出血者，是谓倒经逆行；有三月
一行者，是谓居经；有一年一行者，是谓避年；有一生不行而受胎者，是谓暗经；有受胎之后，月月行经而产子者，是
谓胎盛，俗名垢胎；有受胎数月，血忽大下而胎不坠者，是谓漏胎；此虽异常，而数患之竟不害事也。彼皆以妄为常，
而中土失其主信之道，如人无信行，全赖狡诈以成家，君子不为也。大抵妇人患此者，性情亦必乖张。
门人问曰∶经候不调既得闻命矣，今愿闻调经之法。
曰∶诸家调经之说，是非参半。而萧慎斋以调经莫先于去病，录李氏之论一条，以分因详证治法；录方氏之论一条，
又参以统论二氏之说，深合鄙意，今全录于后。
李氏云∶妇人月水循环，纤 不作而有子。若兼潮热、腹痛，重则咳嗽、汗、呕，或泻，有潮热则血愈消耗，有汗、
咳、呕则气往上行，泻则津偏于后，痛则积结于中，是以必先去病，而后可以滋血调经。就中潮热疼痛，尤为妇人常病。
盖血滞积入骨髓，便为骨蒸；血滞积瘀，与日生新血相搏，则为疼痛；血枯不能滋养百骸，则蒸热于内；血枯胞络火盛，
或挟痰气、食积、寒冷，则为疼痛；凡此诸病，皆阻经候不调，必先去其病，而后可以调经也。
方氏曰∶妇人经病，有月候不调者，有月候不通者；然不调不通中，有兼疼痛者，有兼发热者，此分而为四也。细
详之，不调中，有趋前者，有退后者，趋前为热，退后为虚。
不通中，有血枯者，有血滞者；血滞宜破血，枯宜补也。疼痛中，有时常作痛者，有经前经后作痛者；常时与经前为血
积，以经后为血虚也。发热中，有常时发热者，有经行发热者；常时为血虚有积，经行为血虚而有热也；是四者之中，
又分为八矣。人之气血周流，忽有忧思忿怒，则郁结不行；经前产后，忽遇饮冷形寒，则恶露不尽；此经候不调，不通
作痛，发热所由作也。大抵气行血行，气止血止；故治血病以行气为先，香附之类是也。热则流通，寒则凝塞；故治血
病以热药为佐，肉桂之类是也。
萧慎斋曰∶按妇人有先病而后致经不调者，有因经不调而后生诸病者。如先因病而后经不调，当先治病，病去经自
调；若因经不行而后生病，当先调经，则经调病自除。李氏一论，可谓调经之要，然偏而不全，余故补其未尽之旨。若
方氏分因详症，诚得统论调经大法。
门人问曰∶夫子以月事为月信专主脾胃，不摭《内经》之字句，而独得其精华，究竟从何节得来乎？
曰∶《诗》以“思无邪”蔽之，《礼》以“毋不敬”该之，余此论从“二阳之病发心脾”一节领会出来。今录其原文，
又采集各家之注，愿学人熟读而有得之。《内经》云∶“二阳之病发心脾，有不得隐曲，女子不月，其传为风消，其传为
息贲者，死不治”。马元台注云∶二阳，足阳明胃脉也。为仓廪之官，主纳水谷，乃不能纳受者何也？此由心脾所发耳。
正以女子有不得隐曲之事，郁之于心，故心不能生血，血不能养脾，始焉胃有所受，脾不能化，而继则渐不能纳受，故
胃病发于心脾也。由是水谷衰少，无以化精微之气，而血脉遂枯，月事不能时下矣。余拟用归脾汤，重加鹿茸、麦门冬，
服二十余剂可愈。武叔卿注云∶此节当从“隐曲”推解。人有隐情曲意，难以舒其衷，则气郁而不畅；不畅则心气不开，
脾气不化，水谷日少，不能变化气血，以入二阳之血海；血海无余，所以不月；余拟用归脾汤，加芍药、柴胡。传为风
消者，（风之名，火之化也。消，消瘦也。）发热消瘦，胃主肌肉也；余拟用归脾汤，加丹皮、栀子、地骨皮、芍药。传
为息贲者，喘息上奔，胃气上逆也；余用《金匮》麦门冬汤。人无胃气则死，故云“死不治”。此一节为经血本原之论也。
门人问曰∶妇人经闭，或因家务烦恼，或因胎产、乳子受伤，其不调也有自室女。何以亦有不调之病乎？
余曰∶室女患此，甚于妇人，所以多死。室女乃浑全之人，气血正旺，不应阻塞，竟患经闭不行，若非血海干枯，
则为经脉逆转。血海干枯者，宜用当归补血汤加麦冬、白芍各五钱，炙甘草二钱；虚极者加附子一钱以助之。倘或失治，
则内热咳嗽、肌肉甲错、毫发焦落，而成怯症矣。经脉逆者，宜用《金匮》麦门冬汤、芍药甘草汤，加牛膝、茜草之类，
兼服四乌 骨一芦茹丸以调之。倘或失治，则为吐血、衄血、咳嗽、骨蒸，而成瘵病矣。若肝火炽盛，左胁刺痛，颈生
瘰，佐以逍遥散，加栝蒌、川贝母、生牡蛎、青皮之类。若肝木弦，上寸口鱼际，非药所能治，即与 配则愈，或与
加味逍遥散。若体常怯寒，食少腹胀，佐以六君子汤，加干姜之类；归脾汤、八珍汤可以出入互用。然余又有深一层治
法。忆余乾隆辛丑岁，朱紫坊黄姓之女，年方二十二岁，始因经闭，服行经之药不效，后泄泻不止、食少、骨瘦如柴，
服四神、八味之类，泻益甚，而五更至天明数次，便后带血，余主用《金匮》黄土汤，以赤石脂易黄土，以干姜易附子，
每服加生鹿茸五钱，意以先止其泄泻便红，然后再调其经水，连服八剂，泄泻如故，而经水通矣。又服五剂，泻血俱止。
后服六君子汤加干姜收功。可知鹿茸入冲任督三脉，大能补血，非无情之草木所可比也。又阅喻嘉言《寓意草》，载杨季
登之女，经闭年余，发热食少，肌削多汗，而成劳怯。医见多汗，误谓虚也，投参术，其血愈涸。余诊时，见汗出如蒸
笼气水，谓曰∶此症可疗处，全在有汗。盖经血内闭止，有从皮毛间透出一路，以汗亦血也；设无汗而血不流，则皮毛
干槁而死矣。宜用极苦之药以敛其血，入内而下通于冲脉，则热退经行而血自止，非补药所能效也。于是以龙荟丸日
进三次。月余，忽觉经血略至，汗热稍轻。姑减前丸，只日进一
次。又一月，经血大至，淋漓五日，而诸病全瘳矣。附此二案，为一虚一实之对，学人当一隅而三反之。
门人问曰∶女科书一病一方，且一病而有数方，其方倍于男子。此书于调经一书，止取一十九方，毋乃太简乎？
曰∶《内经》只有十二方，《伤寒论》止有一百一十三方，《金匮》止有二百四十三方，可以谓之方；唐以后合法者甚
少，其余不过汇集药品，不可以名方。而女科所传之方，更为浅陋，大失《神农本经》之旨与伊芳圣制方之法。浅陋之方，
姑任浅陋之医辈用之，浅陋之病家服之，服之不愈，亦无怨言，或日久而病气衰亦自愈，余姑置弗论也。今诸同学皆好
学深思士也。儒者以济人为心，以我之独知俯视一切，未免惊俗。恐济人不广，礼贵从俗，医道何独不然！今取习用之
方而精选之，即如四物汤，本浅近而无深义也，余则加入香附、茯神各二钱为佐，是取铁翁道人之交感丸，参赞其内（交
感者，以气之化于无形也）；又加炙甘草四钱为君，是取仲景先生之复脉汤，主持其际（复脉者，以血之运而不息也）；
变浅近为神奇。惟熟读《内经》、《本经》、仲景书者，方信余言之不谬。又有加减套法∶经血先期而至，加芩、连、知、
柏；后期而至，加姜、桂、艾叶。实者加陈皮、枳实；虚者加人参、白术；大实而闭者，加大黄、枳实、桃仁、牛膝，
更佐以抵当汤、桃仁承气汤；大虚而枯者，加参、术、鹿茸、牛膝外，更加以人参养荣汤。经行而腹痛拒按者，加延胡
索、木香；经已行而腹痛者，加人参、白术、干姜。经水不通、逆行而为吐血、衄血者，加牛膝、泽兰、韭汁、童便。
若腹中素有痞，饮食满闷者，除地黄加枳实、半夏。色紫者，
风也，加荆、防、白芷；黑者，热甚也，加芩、连、丹皮、地骨皮；淡白者，虚也，有挟痰停水以混之，加参、 、陈、
半；色如烟尘、水如屋漏水者，合二陈汤，再加防风、秦艽、苍术；如豆汁者，加芩、连；或带黄混浊者，湿痰也；或
成块作片，血不变者，气滞也；加元胡、枳实、陈皮。色变紫黑者，属热者多，属寒者亦有之，宜察脉审症。此外，若
恶寒、发热、头痛，有汗加桂枝、姜、枣，无汗加麻黄、细辛之类，详于海藏六合汤不赘。其余归脾、逍遥各方，虽不
可
与《内经》四乌 骨一芦茹丸等方并论，而视益母胜金丹、巽顺丸之类，则 乎远矣！
学生问道：“女性以血为本，医生们常说‘血海’，这个概念可以具体指代某个解剖位置吗？”
陈修园回答说：“人体内的血海，就是胞宫（子宫）。它位于膀胱之外，是膀胱的附属腔室。《黄帝内经》说：‘冲脉和任脉都起源于胞中’，这说明男女都有这个血海。
但是，男性使其运行流动，女性使其停止蓄积。运行流动则没有积聚而不会满溢，所以阳气顺应太阳的运行规律，每日有一次宣泄（指精气的化生与排泄）；停止蓄积则有积聚而后满溢，所以阴血顺应月亮的盈亏规律，每月下行一次；这是男女天癸（促进生殖机能成熟的物质）的根本源头。而在妇科这一科中，专门以月经为主。《黄帝内经》说：‘任脉通畅，太冲脉旺盛，月经按时来潮，所以能够受孕。’所谓‘按时’，是指满三十天周期后下行一次，以象征月亮圆满之后就会亏缺，下行不失其时，所以称为‘月信’（月经）。
学生高子问道：“妇科中的高手很少，不能不大力振兴。于是拿着几十种妇科书籍，嘱托我选择并传授给学生。我遍阅之后大有感悟，说道：古人将月经命名为‘月信’，不仅命名确切，而且月经的有无、多少、迟速，以及所有治疗的原理，无不包含在‘信’字之中。五行中的土，对应五常中的‘信’。脾属阴土，胃属阳土，二者都归属于‘信’；‘信’的特点就是按时而下，不违背期限。虽然说是心主生血，肝主藏血，冲脉、任脉、督脉三脉都称为血海，是月经的源头，但其统摄主宰却只在脾胃。脾胃调和，血液自然生成，这是因为血是由水谷的精微之气化生的。如果精血的来源，前后、多少、有无不一致，就叫做不调，不调就是失去了‘信’。《黄帝内经》说：‘土气太过则变得高大厚实。’‘阜’是高耸的意思；‘敦’是浓厚浓重的意思；既然既高又厚，就需要去除多余的邪气，适宜使用平胃散加大黄、白芍药、枳实、桃仁等药物。《黄帝内经》又说：‘土气不足则低洼陷落。’‘卑’是低下的意思；‘监’是陷落、坑洼的意思。既然低洼又陷落，就需要培补正气，适宜使用六君子汤加川芎、当归、柴胡、白芍，以及归脾汤等药物。这是从虚实角度来分析经水不调的。
又有从阴阳偏胜角度分析的。许叔微说：妇女的疾病多是月经忽多忽少，或提前或推后，时常发作疼痛，医生一概称之为经病，不辨别是阴胜还是阳胜，所以服药很少见效。如果阴气胜过阳气，则胞宫寒冷，血液不能正常运行，《内经》所说的‘天寒地冻，水凝成冰’，所以导致月经忽少，且推迟到来。（或者完全闭止不行。）如果阳气胜过阴气，则气血散漫溢出，《内经》所说的‘夏暑地热，经水沸腾’，所以导致月经忽多，且提前到来。（或者一月多次行经，或者崩漏不止。）应当‘辨别其阴阳，调和其气血，使不相悖逆，以平和为准则’。这是许叔微对阴阳之道的总体论述。而我则将‘阴阳’二字，专门用来指代脾胃。因为脾是太阴湿土，得不到阳明燥气的调节，则寒湿盛行；而阴独盛，阴道常虚，这就是《内经》中‘卑监’的含义。胃是阳明燥土，得不到太阴湿气的调节，则燥热盛行；而阳独盛，阳道常实，这就是《内经》中‘敦阜’的含义。至于用药，以四物汤加香附、茯神、炙甘草为主方。阴胜者加干姜、桂枝、附子、吴茱萸及桃仁、红花等药物；阳胜者加知母、黄柏、黄芩、黄连、麦冬等药物。这些方法虽然平平浅显，但也不可废弃。若要探求其中奥妙，《金匮要略》中的温经汤一方，无论阴阳、虚实、闭塞、崩漏、老少，善于运用它没有不随手奏效的。这不仅是当今学习妇科的人听了会吐舌头惊讶，即使是几百年来注释《金匮要略》的医家，有的见识不到而不能言说，有的珍视为枕边秘而不肯言说。如今我陈修园老了！不得不选择合适的人传承，但在传授后又嘱咐他们说：《灵枢经》记载黄帝对雷公说：‘这是先师所禁止的，割臂歃血盟誓才能传授的内容。’凡是思虑难以达到的方剂，如果轻易示人，则真气泄露而不神奇，必须选择学问渊博、心地纯正厚重的人，然后才传授给他。
学生问道：“女人的月经，一个月来一次，这是常态；或提前或推后，或通畅或阻塞，这是病态；偶尔有不属于疾病的特殊情况，我想听听其中的说法。”
我说：“天下的事有常态就有变态。妇女在月经应来的时期，经血不下行，只见吐血、鼻衄，或眼耳出血的，这叫倒经逆行；有三个月来一次的，这叫居经；有一年来一次的，这叫避年；有一生都不来月经却能怀孕的，这叫暗经；有怀孕之后，每个月仍行经直到生产孩子的，这叫胎盛，俗称垢胎；有怀孕数月，突然大量出血但胎儿不坠落的，这叫漏胎；这些虽然异常，但患此病的人竟然也不妨害事情。那些人都把反常当作正常，而中土（脾胃）失去了主宰‘信’的原则，就像人没有信用，全赖狡诈来成家立业，君子是不为之的。大抵患有这些病症的妇人，性情也一定乖张怪异。
学生问道：“关于月经不调已经听您教诲了，现在想听听调经的方法。”
我说：“各家关于调经的说法，对错参半。而萧慎斋认为调经莫先于去病，收录李氏的一条论述，详细分析病因并详述证治法；收录方氏的一条论述，又综合参考两家的观点，深合我的意旨，现在全部抄录在后面。
李氏说：妇女月经循环，如果没有其他兼症而有生育能力。如果兼有潮热、腹痛，重则咳嗽、出汗、呕吐，或腹泻，有潮热则血液更加消耗，有汗、咳、呕则气机上逆，腹泻则津液偏走后方，痛则积结于中，所以必须先去除疾病，然后才可以滋血调经。其中潮热疼痛，尤为妇女常见病。因为血滞积入骨髓，就成为骨蒸劳热；血滞积瘀，与每天生成的新血相搏，就成为疼痛；血枯不能滋养百骸，则在体内产生蒸热；血枯胞络火盛，或挟带痰气、食积、寒冷，则成为疼痛；凡此种种疾病，都阻碍经候不调，必须先去除其病，然后才可以调经。
方氏说：妇女经病，有月经失调的，有月经不通的；然而在失调和不通中，有兼疼痛的，有兼发热的，这就分为四类了。仔细详查，失调中，有提前的，有推后的，提前为热，推后为虚。不通中，有血枯的，有血滞的；血滞宜破血，血枯宜补血。疼痛中，有经常作痛的，有经前经后作痛的；经常痛与经前痛为血积，经后痛为血虚。发热中，有经常发热的，有经期发热的；经常发热为血虚有积，经期发热为血虚而有热；在这四种情况中，又细分为八种了。人的气血周流全身，忽然有忧思忿怒，则郁结不行；经前产后，忽然遇到饮冷受寒，则恶露不尽；这是经候不调、不通、作痛、发热产生的原因。大抵气行则血行，气止则血止；所以治疗血病以行气为先，如香附之类的药物。热则流通，寒则凝塞；所以治疗血病以热药为辅助，如肉桂之类的药物。
萧慎斋说：按妇女有病在先而后导致月经不调的，有因月经不调而后生出各种病的。如果先因病而后经不调，应当先治病，病去经自调；如果因经不行而后生病，应当先调经，则经调病自除。李氏的论述，可以说是调经的要诀，然而偏颇而不全面，所以我补充其未尽的意旨。至于方氏分因详症，确实得到了统论调经的大法。
学生问道：“老师以月事为月信专主脾胃，不拘泥于《内经》的字句，而独得其精华，究竟是从哪一节领悟出来的呢？”
我说：“《诗经》用‘思无邪’概括它，《礼记》用‘毋不敬’涵盖它，我的这个论点是从‘二阳之病发心脾’这一节领会出来的。现在抄录其原文，又采集各家的注解，希望学习者熟读而有心得。《黄帝内经》说：‘二阳的病发于心脾，有难以启齿的隐情，女子就会不来月经，如果传变为风消（消瘦），传变为息贲（喘息上奔），则是死证，无法治愈。’马元台注解说：二阳，指足阳明胃脉。作为仓廪之官，主管接纳水谷，如果不能纳受是什么原因呢？这是由于心脾所引发的。正因为女子有难以启齿的隐情，郁结在心中，所以心不能生血，血不能养脾，起初胃还能接受食物，但脾不能运化，继而逐渐不能纳受，所以胃病发于心脾。由此水谷衰少，无法化生精微之气，血脉遂枯竭，月经不能按时来潮了。我拟用归脾汤，重加鹿茸、麦门冬，服用二十多剂可愈。武叔卿注解说：这一节应当从‘隐曲’推理解释。人有隐情曲意，难以抒发衷肠，则气郁而不畅；不畅则心气不开，脾气不化，水谷日渐减少，不能变化气血，进入二阳的血海；血海无余，所以不来月经；我拟用归脾汤，加芍药、柴胡。传变为风消的，（风之名，是火的转化。消，是消瘦的意思。）发热消瘦，胃主肌肉；我拟用归脾汤，加丹皮、栀子、地骨皮、芍药。传变为息贲的，喘息上奔，胃气上逆；我用《金匮要略》麦门冬汤。人没有胃气则死，所以说‘死不治’。这一节是经血本原的论述。
学生问道：“妇女经闭，或因家务烦恼，或因胎产、哺乳受伤，其不调也有来自未婚少女的。为什么也会有不调的病呢？”
我说：“未婚少女患此病，比已婚妇女更严重，所以多致死。未婚少女是身体浑全之人，气血正旺盛，不应阻塞，竟患经闭不行，如果不是血海干枯，就是经脉逆转。血海干枯者，适宜用当归补血汤加麦冬、白芍各五钱，炙甘草二钱；虚极者加附子一钱以助之。倘若失治，则内热咳嗽、肌肤甲错、毫发焦落，而成怯弱之症了。经脉逆者，适宜用《金匮要略》麦门冬汤、芍药甘草汤，加牛膝、茜草等药物，兼服四乌鲗骨一芦茹丸以调理。倘若失治，则为吐血、鼻衄、咳嗽、骨蒸，而成痨瘵病了。如果肝火炽盛，左胁刺痛，颈部生瘰疬，佐以逍遥散，加栝蒌、川贝母、生牡蛎、青皮等药物。如果肝脉弦急，上至寸口鱼际部位，非药物所能治愈，即使给予配伍恰当也能痊愈，或者用加味逍遥散。如果体质常感怯寒，食少腹胀，佐以六君子汤，加干姜等药物；归脾汤、八珍汤可以交替互用。然而我又有一种更深一层的治法。回忆我在乾隆辛丑年，朱紫坊黄姓的女儿，年仅二十二岁，起初因经闭，服用通经的药物无效，后来泄泻不止、食少、骨瘦如柴，服用四神丸、八味丸之类，腹泻更甚，而且五更至天明数次，便后带血，我主张用《金匮要略》黄土汤，以赤石脂代替黄土，以干姜代替附子，每服加生鹿茸五钱，意图是先止其泄泻便红，然后再调其经水，连服八剂，泄泻依旧，而经水通了。又服五剂，泻血俱止。后来服用六君子汤加干姜收功。可知鹿茸入冲任督三脉，大能补血，不是无情的草木所能比拟的。又阅读喻嘉言《寓意草》，记载杨季登的女儿，经闭一年多，发热食少，肌削多汗，而成劳怯。医生见多汗，误认为是虚证，投予人参、白术，其血更加枯竭。我诊察时，见汗出如蒸笼气水，说道：‘这个病症可治疗的地方，全在有汗。’因为经血内闭止，有从皮毛间透出一路，因为汗也是血；假如无汗而血不流，则皮毛干槁而死矣。适宜用极苦的药物以收敛其血，入内而下通于冲脉，则热退经行而血自止，不是补药所能奏效的。于是让龙荟丸每日进服三次。月余，忽然觉得经血略至，汗热稍轻。暂减前丸，只每日进服一次。又一月，经血大至，淋漓五日，而诸病全愈了。附上这两个医案，为一虚一实的对照，学习者应当举一反三。
学生问道：“妇科书是一病一方，而且一病而有数方，其方剂数量倍于男子。这本书关于调经一书，只选取十九个方剂，未免太简略了吧？”
我说：“《黄帝内经》只有十二方，《伤寒论》只有一百一十三方，《金匮要略》只有二百四十三方，可以称之为方；唐以后符合法度的方剂很少，其余不过是汇集药品，不可以称为方。而女科所传的方剂，更为浅陋，大失《神农本草经》的宗旨和张仲景制方的法则。浅陋的方剂，姑且让浅陋的医生使用，浅陋的病人服用，服用不愈，也没有怨言，或者日久病气衰退也会自愈，我姑且搁置不论。如今各位同学都是好学深思之士。儒者以济世救人为心，以我之独知俯视一切，未免惊俗。恐怕济人不广，礼仪贵在从俗，医道何尝不是如此！现在选取习用的方剂而精选之，就如四物汤，本是浅近而无深义的，我却加入香附、茯神各二钱为佐药，这是取铁翁道人的交感丸，参赞其内（交感，是指以气之化于无形）；又加炙甘草四钱为君药，这是取张仲景先生的复脉汤，主持其际（复脉，是指以血之运而不息）；变浅近为神奇。只有熟读《内经》、《本经》、仲景书的人，才相信我的话不谬。还有加减套法：经血先期而至，加黄芩、黄连、知母、黄柏；后期而至，加干姜、桂枝、艾叶。实证加陈皮、枳实；虚证加人参、白术。大实而闭者，加大黄、枳实、桃仁、牛膝，更佐以抵当汤、桃仁承气汤；大虚而枯者，加人参、白术、鹿茸、牛膝外，更加以人参养荣汤。经行而腹痛拒按者，加延胡索、木香；经已行而腹痛者，加人参、白术、干姜。经水不通、逆行而为吐血、鼻衄者，加牛膝、泽兰、韭汁、童便。若腹中素有痞块，饮食满闷者，除去地黄加枳实、半夏。色紫者，是风邪，加荆芥、防风、白芷；色黑者，是热甚，加黄芩、黄连、丹皮、地骨皮；色淡白者，是虚证，有挟痰停水混杂其中，加人参、茯苓、陈皮、半夏；色如烟尘、水如屋漏水者，合二陈汤，再加防风、秦艽、苍术；如豆汁者，加黄芩、黄连；或带黄混浊者，是湿痰；或成块作片，血不变者，是气滞；加元胡、枳实、陈皮。色变紫黑者，属热者多，属寒者亦有之，宜察脉审症。此外，若恶寒、发热、头痛，有汗加桂枝、生姜、大枣，无汗加麻黄、细辛等药物，详见海藏六合汤，不再赘述。其余归脾、逍遥各方，虽然不可与《内经》四乌鲗骨一芦茹丸等方并列讨论，而比起益母胜金丹、巽顺丸之类，则高明得远了！”
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!"