李东垣曰∶经水漏不住有二。妇人脾胃虚损，致命门脉沉细而数疾，或沉弦而洪大有力，寸关脉亦然。
皆由脾胃有亏，下陷于肾，与相火相合，湿热下迫，经漏不止，其色紫黑，如夏月腐肉之臭。中有白带者，脉
必弦细，寒作于中；有赤带者，其脉洪数，病热明矣，必腰痛成脐下痛。临经欲行，而先发寒热往来，两胁急
缩，兼脾胃证出见，或四肢困倦，心烦闷不得眠卧，心下急，宜大补脾胃而升降气血，可一服而愈。或贵而后
贱，富而后贫，病名脱营者，心气不足，其火大炽，旺于血脉之中，又或脾胃饮食失节，火乘其中，形质肌肉
颜色似不病者，此心病也，下形于脉，故脾胃饮食不调，其证显矣而经水不时而下，或适来适断，暴下不止。
治当以大补气血之剂，补养脾胃，微加镇坠心火之药治其心，补阴
泻阳，经自止矣，《痿论》云∶悲哀太甚则胞络绝，胞络绝则阳气内动，发则心下满，数溲血也。故经曰∶
大经空虚，发则肌痹，传为脉痿，此之谓也。治宜升阳益胃汤。血脱益气，古人之法也。先补胃气以助生长，
故曰阳生阴长，诸甘药为之先务。
薛立斋曰∶血崩，经云∶阴虚阳搏，谓之崩。又云∶阳络伤则血外溢，阴络伤则血内溢。又云∶脾统血，
肝藏血。其为患因脾胃虚损，不能摄血归源；或因肝经有火，血得热而下行；或因肝经有风，血得风而妄行；
或因怒动肝火，血热而沸腾；或因肝经郁结，血伤而不归经；或因怒动肝火悲哀太过，胞络伤而下崩。治疗之
法∶脾胃虚弱者；六君子汤加芎、归、柴胡；脾胃虚陷者，补中益气加白芍、山栀；肝经血热，四物加柴、
栀、苓、术；肝经风热，加味逍遥，或小柴胡加山栀、白芍、丹皮；若怒动肝火，亦用前药；脾经郁火，归脾加
山栀、柴胡、丹皮；哀伤胞络，四君加升、柴、山栀。故东垣、丹溪诸先生云∶凡下血证，须用四君子以
收功。斯言厥有旨哉。若大去血后，毋以脉诊，当急用独参汤救之。其发热、咳嗽脉数，乃是元气虚弱，假热
之脉也，尤当用人参之类。此等证候，无不由脾胃先损，故脉洪大，察其有胃气受补可救。误用寒凉之药，复
伤脾胃生气，反不能摄血归元，是速其危也。
薛立斋医案
一妇人，内热作渴，饮食少思，腹内近左初如鸡卵，渐大四寸许，经水三月一至，肢体消瘦，齿颊似疮，
脉洪数而虚，左关尤甚，此肝脾郁结之证。外贴阿魏膏，午前用补中益气汤，午后以加味归脾汤。两月许，
肝火少退，脾胃尚健，仍与前汤送六味丸，午后又用逍遥散送归脾丸。又月余，日用芦荟丸二服，空心以逍
遥散下，晡时以归脾汤下，喜其调理谨慎，年余而愈。
一妇人，发热口干，月经不调，两腿无力，服祛风渗湿之剂，腿痛体倦，二膝浮肿，经事不通。余作脾、
肝、肾三经血虚火燥，证名鹤膝风，用六味丸、八味丸，兼服两月，形体渐健，饮食渐进，膝肿渐消，不半载而痊。
前证若脾肾虚寒，腿足软痛，或足膝枯细，用八味丸。若饮食过多，腿足或臀后酸痛，或浮肿作胀，用补中益气加茯苓、半夏主之。
一妇人，性沉静，勤于女工，善怒，小腹内结一块，或作痛，或痞满，月经不调，恪服伐肝之剂，内热寒热，胸膈
不利，饮食不甘，形体日瘦，牙龈蚀烂。此脾土不能生肺金，肺金不能生肾水，肾水不能生肝木，当滋化源，用补中益气、六味地黄，至仲春而愈。
松江太守何恭人，性善怒，腹聚一块年余，形体骨立，倏然往来， 蚀透腮，或泥春木旺克土，仍行伐肝。时季冬，
肝脉洪数，按之弦紧，余脉微弱。余曰∶洪数弦紧，肝经真气发见而邪气实也，自保不及，何能克土？况面色青中隐白，
乃肾水不足，肝木亏损，肺金克制，惟虑至春木不能发生耳。勉用壮脾胃、滋肾水，二剂，肝脉悉退。后大怒，耳内出血，肝脉仍大，按之如无，烦躁作渴。此无根之火，以前药加肉桂，二剂，肝脉仍敛，热渴顿退。复因大怒，
以致饮食不进，果卒于季冬辛巳日。此木衰弱而金刑克，信矣。
一妇人，经候过期，发热倦怠，或用四物、黄连之类，反两月一度，且少血而成块。又用峻药通之，两目如帛
所蔽。余曰∶脾为诸阴之首，目为血脉之宗，此脾伤，五脏皆为失所，不能归于目矣。遂用补中益气、济生归脾二汤，专主脾胃，年余而愈。
一妇人，年四十，索性急，先因饮食难化，月经不调，服理气化痰药，反肚腹膨胀，大便泄泻；又加乌
药、蓬术，肚腹肿胀，小便不利；加猪苓、泽泻，痰喘气急；手足厥冷，头面肢体肿胀，指按成窟，脉沉细，
右寸为甚。余曰∶此脾肺之气虚寒，不能通调水道，下输膀胱，渗泄之令不行，生化之气不运。即东垣所云∶
水饮留积，若土之在雨中，则为泥矣。得和风暖日，水湿去而阳化，自然万物生长。喜其脉相应，遂与金匮
加减肾气丸料服之，小便即通。数剂肿胀消半，四肢渐温，自能转侧。又与六君子加木香、肉桂、炮姜治之，
全愈。后不戒七情饮食，即为泄泻，仍用前药加附子五分而安。
一妇人，素有头晕，不时而作，月经迟而少。余以为中气虚，不能上升而头晕，不能下化而经少，用补
中益气汤而愈。后因劳而作，月经如涌，此劳伤火动，用前汤加五味子一剂、服之即愈。前证虽云亡血过多，
气无所附，实因肺气亏损。
西宾钱思曾云∶室年三十，尚无嗣，月经淋漓无期，夫妇异处者几年矣，思曾欲为娶外家，以谋诸余。余
曰∶此郁怒伤肝，脾虚火动，而血不归经，乃肝不能藏，脾不能摄也。当清肝火，补脾气，遂与加味归脾、逍
遥二药。送至其家，仍告其姑曰∶服此病自愈，而当受胎，外家可无娶也。果病愈，次年生子。
一妇人，多怒，经行或数日或半月后止，三年后淋漓无期，肌体倦瘦，口渴内热，盗汗如洗，日晡热甚。
余用参、术、 、归、茯神、远志、枣仁、麦冬、五味、丹皮、龙眼肉、炙草、柴胡、升麻，治之获痊。
此证先有怒动肝火，血热妄行，后乃脾气下陷，不能摄血归源，故用前药。若胃热亡津液而
经不行，宜清胃。若心火亢甚者，宜清心。若服燥药过多者，宜养血。若病久气血衰，宜健脾胃。
一妇人，性善怒，产后唇肿内热，月水不调，食少作呕，大便不实，唇出血水。用理气消导，胸膈痞
满，头目不清，唇肿经闭；用清胃行血，肢体倦怠，发热烦躁，涎水涌出。欲用通经之剂。余曰∶病本七情，
肝脾虚损，数行攻伐，元气益虚者耳。法当补阴益阳，遂以加味归脾汤、加味逍遥散、补中益气汤，如法调
治，元气渐复，唇疮亦愈。后因怒，寒热耳痛，胸胁胀闷，唇 肿甚，此是怒动肝火而血伤，遂用四物合小柴
胡加山栀，顿愈。后又怒，胁乳作胀，肚腹作痛，呕吐酸涎，饮食不入，小水不利，此是怒动肝木克脾土，乃
用补脾气、养脾血而愈。又因劳役怒气，饮食失节，发热喘渴，体倦不食，去血如崩，唇肿炽甚，肝经有火。
脾经气虚，遂用补中益气加黑栀、丹皮、芍药而愈。此证每见，但治其疮，不固其本，而死者多矣。
一妇人，年六十有四，久郁怒，头痛寒热，春间乳内时痛，服流气饮之类益甚，不时有血如经行。又大
惊恐，饮食不进，夜寐不宁，乳肿及两胁， 痛如炙，午前后色赤。余以为肝脾郁火血燥，先以逍遥散加酒炒
黑龙胆一钱，山栀半钱，两剂顿退，又二剂而全消。再用归脾加炒栀、贝母，诸证悉退。
一妇人，因怒血崩，久不已，面青黄而或赤。此肝木制脾土而血虚也，用小柴胡合四物，以清肝火、生
肝血；又用归脾、补中二汤，益脾气以生肝血而痊。若因肝经有风热而血不宁者，用防风一味为丸，以兼证
之药煎送。或肝经火动而不宁者，用条芩炒为丸，以兼证之药煎送，无有不效。
一妇人，性急，每怒非太阳，耳、项、喉、齿、胸、乳
作痛，则胸满吞酸，吐泻少食，经行不止。此皆肝火之证，肝自病则外证见，土受克则内症作。若自病见，用
四物加白术、茯苓、炒山栀、炒龙胆；若内症作，用四君加柴胡、白芍、神曲、吴萸炒连，诸症渐愈。惟月
经不止，是血分有热，脾气尚虚，以逍遥散倍用白术、茯苓、陈皮，又以补中益气加酒炒芍药，兼服而调。
归大化内人，患月事不期，崩血昏愦，发热不寐。或谓血热妄行，投以寒剂益甚；或以胎成受伤，投以
止血，亦不效。余曰∶此脾气虚弱，无以统摄故耳。法当补脾而血自止，用补中益气汤加炮姜，不数剂而效。
惟终夜少睡惊悸，其家另服八珍汤，更不效。余曰∶杂矣！乃与归脾汤加炮姜，以补心肾，遂如初。
一妇人，素有胃火，服清胃散而安，后因劳役，燥渴内热，肌肉消瘦，月经不行。此胃火消烁阴血，用逍
遥散加丹皮、炒山栀以清胃热，用八珍汤加茯苓、远志以养脾血，而经自行。
一妇，因劳耳鸣头痛体倦，此元气不足，用补中益气加麦冬、五味而痊。三年后，因饮食劳倦，前症
益甚，月经不行，晡热内热，自汗盗汗，用六味地黄丸、补中益气汤，顿愈。前症若因血虚有火，用四物加山
栀、柴胡；不应，八珍加前药。若气虚弱，用四君子。若怒便耳聋或鸣者，实也，小柴胡加芎、归、山栀；
虚用补中益气加山栀。若午前甚作火治，用小柴胡加炒连、炒栀，气虚用补中益气。午后作血虚，用四物加白
术、茯苓。若阴虚火动，或兼痰甚作渴，必用地黄丸以壮水之主。经云∶头痛耳鸣，九窍不利，肠胃之所生
也。脾胃一虚，耳目九窍皆为之病。
《治法纲》曰∶《内经》方，血枯一证，与血膈相似，皆
经闭不通之候。然而枯与膈则相反，有如冰炭。夫枯者，枯竭之谓；膈者，阻隔之谓。血本不虚，而或气或
寒或积，有所逆，病发于暂，其症则或痛或实，必通之，以血行而愈，此可攻者。枯者，其来有渐，脾胃气
乏，冲任内竭，其症无形，此必不可通者也。夫血既枯矣，只当补养阴气，使其血充。若勉强通之，则枯愈
枯，不危何待耶。
李东垣说：月经淋漓不尽有两种情况。妇女因脾胃虚弱受损，导致命门脉象沉细且数疾，或者沉弦而洪大有力，寸口和关口的脉象也是如此。这全是因为脾胃亏损，气机下陷于肾，与相火相结合，湿热下迫，导致经血漏泄不止，血色紫黑，气味像夏天腐烂的肉一样臭。如果伴有白带，脉象必定是弦细的，说明体内有寒；如果有赤带，脉象洪数，说明病属热，必然伴有腰痛直至脐下疼痛。在月经将要来潮时，先出现忽冷忽热的症状，两胁紧缩拘急，同时显现出脾胃病的症状，如四肢困倦、心烦胸闷无法安睡、心下部紧迫等，应当大补脾胃以升降气血，往往一服药就能痊愈。或者是地位尊贵后变得卑贱，富裕后变得贫穷，这种病名叫“脱营”，由于心气不足，心火极度炽盛，旺盛于血脉之中；又或者是脾胃饮食没有节制，火热之邪乘虚侵入中焦，虽然形体、肌肉、面色看起来不像有病的人，但这实际上是心病，反映在脉象上，所以脾胃饮食不调的症状明显，导致月经不时而下，或刚来即断，或突然大量出血不止。治疗应当用大补气血的药剂，补养脾胃，稍微加入一些镇降心火的药物来治疗心脏，通过补阴泻阳的方法，经血自然停止。《痿论》中说：“悲哀太过会导致胞络闭塞，胞络闭塞则阳气在内扰动，发作时心下部胀满，频繁小便并尿血。”所以说：“大经脉空虚，发作时肌肉麻痹，传变为脉痿”，说的就是这种情况。治疗适宜用升阳益胃汤。血脱证用益气法，这是古人的治法。先补养胃气以助生长，所以说“阳生阴长”，各种甘味药是首要任务。
薛立斋说：血崩，《内经》说：“阴虚阳搏，称为崩。”又说：“阳络受伤则血液外溢，阴络受伤则血液内溢。”又说：“脾统血，肝藏血。”其致病原因，有的是因为脾胃虚弱受损，不能摄血归源；有的因为肝经有火，血液受热而下行；有的因为肝经有风，血液受风而妄行；有的因为发怒触动肝火，血液受热沸腾；有的因为肝经郁结，血液受伤而不归经；有的因为发怒触动肝火或悲哀太过，损伤胞络而导致下崩。治疗方法：脾胃虚弱者，用六君子汤加川芎、当归、柴胡；脾胃虚陷者，用补中益气汤加白芍、山栀；肝经血热，用四物汤加柴胡、山栀、茯苓、白术；肝经风热，用加味逍遥散，或小柴胡汤加山栀、白芍、丹皮；如果是发怒触动肝火，也用前面的药方；脾经郁火，用归脾汤加山栀、柴胡、丹皮；哀伤胞络，用四君子汤加升麻、柴胡、山栀。所以东垣、丹溪各位先生说：“凡是下血的病症，必须用四君子汤来收功。”这话很有深意啊。如果在大量失血之后，不要依赖脉诊，应当紧急使用独参汤来抢救。那些发热、咳嗽、脉数的症状，其实是元气虚弱导致的假热脉象，尤其应当用人参之类的药物。这些证候，无不是由脾胃先受损引起的，所以脉象洪大，只要观察到有胃气、能够耐受补益，就可以救治。误用寒凉的药物，再次伤害脾胃的生气，反而不能摄血归元，这是加速死亡的危险做法。
薛立斋医案：
有一位妇人，自觉内热口渴，饮食减少思虑，腹部左侧起初像鸡蛋大小，逐渐增大到四寸左右，月经三个月来一次，身体消瘦，牙齿和脸颊像生疮一样，脉象洪数但按之无力，左关脉尤为严重，这是肝脾郁结的证候。外部贴敷阿魏膏，午前服用补中益气汤，午后服用加味归脾汤。两个月左右，肝火稍退，脾胃功能尚健，仍然用前面的汤剂送服六味丸，午后又用逍遥散送服归脾丸。又过了一个多月，每天早晚各服两次芦荟丸，空腹时用逍遥散送下，傍晚时用归脾汤送下，庆幸她调理谨慎，一年多才痊愈。
另一位妇人，发热口干，月经不调，双腿无力，服用祛风渗湿的药物后，腿痛身体疲倦，双膝浮肿，月经不通。我认为是脾、肝、肾三经血虚火燥，证名鹤膝风，使用六味丸、八味丸，兼服两个月，形体逐渐健壮，饮食逐渐增加，膝盖肿胀逐渐消退，不到半年就痊愈了。前一种证候如果是脾肾虚寒，腿足软痛，或者足膝枯细，用八味丸。如果饮食过多，腿足或臀部后方酸痛，或者浮肿作胀，用补中益气汤加茯苓、半夏为主治疗。
第三位妇人，性格沉静，勤于女红，容易发怒，小腹内结成一团块，有时疼痛，有时痞满，月经不调，严格服用伐肝的药物后，出现内热寒热往来，胸膈不利，饮食不甘美，身体日渐消瘦，牙龈蚀烂。这是因为脾土不能生肺金，肺金不能生肾水，肾水不能生肝木，应当滋生化之源，用补中益气汤、六味地黄丸，到仲春时节痊愈。
松江太守何恭人，性格易怒，腹中聚积一块肿块一年多了，身体瘦得皮包骨头，肿块倏然游走，侵蚀穿透腮部。有人说是春季木旺克土，仍然采用伐肝的方法。当时是季冬，肝脉洪数，按之弦紧，其他脉微弱。我说：“洪数弦紧，是肝经真气显露而邪气实盛的表现，自身保全都来不及，怎么能克制脾土呢？况且面色青中隐白，是肾水不足，肝木亏损，肺金克制，只担心到了春天木气不能发生罢了。”勉强使用壮脾胃、滋肾水的药物，两剂后，肝脉完全消退。后来大怒，耳内出血，肝脉仍然大，按之如无，烦躁口渴。这是无根之火，用前面的药加肉桂，两剂后，肝脉收敛，热渴顿时减退。又因大怒，导致饮食不进，果然在季冬辛巳日去世。这是木衰弱而被金刑克，确实如此。
第四位妇人，月经过期，发热倦怠，有人用四物汤、黄连之类的药物，反而变成两个月来一次，而且血量少并形成血块。又用峻猛的药物通经，导致两眼像被布遮住一样模糊。我说：“脾为诸阴之首，目为血脉之宗，这是脾受伤，五脏都失去所依，不能滋养眼睛了。”于是用补中益气汤、济生归脾汤二方，专门主治脾胃，一年多才痊愈。
第五位妇人，四十岁，性格急躁，先前因为饮食难消化，月经不调，服用理气化痰药，反而肚腹膨胀，大便泄泻；又加上乌药、蓬术，肚腹肿胀，小便不利；再加猪苓、泽泻，痰喘气急；手足厥冷，头面肢体肿胀，指按成坑，脉沉细，右寸脉尤为明显。我说：“这是脾肺之气虚寒，不能通调水道，下输膀胱，渗泄的命令不执行，生化之气不运行。就是东垣所说的：‘水饮留积，就像泥土在下雨中，就变成了泥浆。’得到和风暖日，水湿去除而阳气化生，自然万物生长。庆幸她的脉象与证候相应，于是给予金匮加减肾气丸料服用，小便随即通畅。几剂后肿胀消了一半，四肢逐渐温暖，自己能翻身转动。又用六君子汤加木香、肉桂、炮姜治疗，完全痊愈。后来不戒七情饮食，又发生泄泻，仍用前药加附子五分而安定。
第六位妇人，素有头晕，不时发作，月经推迟且量少。我认为这是中气虚，不能上升导致头晕，不能下化导致经少，用补中益气汤而痊愈。后来因为劳累而发作，月经如涌，这是劳伤火动，用前面的汤剂加五味子一剂，服用后即愈。前一种证候虽然说亡血过多，气无所依附，实际上是因为肺气亏损。
西宾钱思曾说：三十岁，还没有后代，月经淋漓无期，夫妇分居几年了，思曾想为他娶妾，来征求我的意见。我说：“这是郁怒伤肝，脾虚火动，而血不归经，是肝不能藏血，脾不能摄血。应当清肝火，补脾气，于是给予加味归脾汤、逍遥散两种药。送到他家，还告诉他的婆婆说：‘服用这个病会自愈，并且会受孕，可以不用娶妾了。’果然病愈，次年生子。
第七位妇人，多怒，月经来潮或几天或半个月后停止，三年后淋漓无期，肌体疲倦消瘦，口渴内热，盗汗如雨，下午发热严重。我用人参、白术、（此处原文缺字，推测为熟地或类似补血药，依上下文及常见配伍，结合后文列举药材，暂略或视为泛指）、当归、茯神、远志、枣仁、麦冬、五味子、丹皮、龙眼肉、炙甘草、柴胡、升麻治疗，获得痊愈。此证先有怒动肝火，血热妄行，后来是脾气下陷，不能摄血归源，所以用前面的药。如果是胃热亡津液而经不行，宜清胃。如果心火亢盛严重的，宜清心。如果服用燥药过多的，宜养血。如果病久气血衰弱的，宜健脾胃。
第八位妇人，性格易怒，产后嘴唇肿内热，月事不调，食少作呕，大便不实，嘴唇出血水。用理气消导药，导致胸膈痞满，头目不清，唇肿经闭；用清胃行血药，导致肢体倦怠，发热烦躁，涎水涌出。想要用通经的药物。我说：“病本源于七情，肝脾虚损，多次攻伐，元气更加虚弱。治法应当补阴益阳，于是用加味归脾汤、加味逍遥散、补中益气汤，依法调治，元气逐渐恢复，唇疮也痊愈了。后来因为发怒，寒热耳痛，胸胁胀闷，唇肿严重，这是怒动肝火而血受伤，于是用四物汤合小柴胡汤加山栀，顿时痊愈。后来又发怒，胁肋乳房作胀，肚腹作痛，呕吐酸涎，饮食不入，小便不利，这是怒动肝木克制脾土，于是用补脾气、养脾血的方法而痊愈。又因劳役怒气，饮食失节，发热喘渴，体倦不食，去血如崩，唇肿炽盛，这是肝经有火，脾经气虚，于是用补中益气汤加黑山栀、丹皮、芍药而痊愈。这种证候经常见到，如果只治疗疮疡，不固护根本，死去的人很多了。
第九位妇人，六十四岁，长期郁怒，头痛寒热，春天时乳房内部时常疼痛，服用流气饮之类的药物更严重，不时有血像月经一样流出。又大惊恐，饮食不进，夜寐不宁，乳房肿胀及两胁，疼痛如火烤，午前后颜色发红。我认为是肝脾郁火血燥，先用逍遥散加酒炒黑龙胆一钱，山栀半钱，两剂后顿时消退，又两剂后完全消除。再用归脾汤加炒山栀、贝母，各种症状全部消退。
第十位妇人，因为发怒血崩，久久不停，面色青黄时而发红。这是肝木克制脾土而血虚，用小柴胡汤合四物汤，以清肝火、生肝血；又用归脾汤、补中益气汤二方，益脾气以生肝血而痊愈。如果是因为肝经有风热而血不宁的，用防风一味做成丸药，用兼证的药煎汤送服。或者肝经火动而不宁的，用条芩炒成丸药，用兼证的药煎汤送服，没有不有效的。
第十一位妇人，性格急躁，每次发怒如果不是太阳经受邪，耳朵、项部、喉咙、牙齿、胸部、乳房就会作痛，则胸满吞酸，吐泻少食，月经不止。这都是肝火的证候，肝自病则外证显现，脾土受克则内症发作。如果是肝自病显现，用四物汤加白术、茯苓、炒山栀、炒龙胆；如果是内症发作，用四君子汤加柴胡、白芍、神曲、吴茱萸炒黄连，各种症状逐渐痊愈。只有月经不止，是血分有热，脾气尚虚，用逍遥散倍用白术、茯苓、陈皮，又以补中益气汤加酒炒芍药，兼服而调。
归大化内人，患月经不定期，崩血昏愦，发热不寐。有人说血热妄行，投以寒剂更严重；有人说胎成受伤，投以止血药，也不见效。我说：“这是脾气虚弱，无以统摄的缘故。治法应当补脾而血自止，用补中益气汤加炮姜，不几剂就见效。只是整夜少睡惊悸，家属另外服用八珍汤，更不效。我说：“太杂乱了！”于是给予归脾汤加炮姜，以补心肾，于是如初。
第十二位妇人，素有胃火，服用清胃散而安定，后来因为劳役，燥渴内热，肌肉消瘦，月经不行。这是胃火消烁阴血，用逍遥散加丹皮、炒山栀以清胃热，用八珍汤加茯苓、远志以养脾血，而经自行。
第十三位妇人，因为劳累耳鸣头痛体倦，这是元气不足，用补中益气汤加麦冬、五味子而痊愈。三年后，因为饮食劳倦，前症更严重，月经不行，下午发热内热，自汗盗汗，用六味地黄丸、补中益气汤，顿时痊愈。前一种证候如果是因为血虚有火，用四物汤加山栀、柴胡；不应，用八珍汤加前药。如果气虚弱，用四君子汤。如果发怒导致耳聋或鸣响的，属实，用小柴胡汤加川芎、当归、山栀；虚的用补中益气汤加山栀。如果午前严重作火治，用小柴胡汤加炒黄连、炒山栀，气虚的用补中益气汤。午后作血虚，用四物汤加白术、茯苓。如果阴虚火动，或者兼痰甚作渴，必用地黄丸以壮水之主。《内经》说：“头痛耳鸣，九窍不利，肠胃之所生也。”脾胃一虚，耳目九窍都为之生病。
《治法纲》说：《内经》中的方剂，血枯一证，与血膈相似，都是经闭不通的候象。然而枯与膈则相反，有如冰炭。所谓枯，是枯竭的意思；所谓膈，是阻隔的意思。血液本来不虚，或者因为气逆、或者因为寒凝、或者因为积滞，有所逆乱，病发于暂时，其症状则是或痛或实，必须通利，以使血行而愈，这是可以攻下的。所谓枯，它的到来是渐进的，脾胃气乏，冲任内竭，其症状无形，这是必不可通的。既然血已经枯了，只应当补养阴气，使其血充。如果勉强通之，则枯更枯，不危险还等什么耶。
Li Dongyuan said: There are two types of menorrhagia (prolonged menstrual bleeding) that do not stop. In women, deficiency and damage to the Spleen and Stomach lead to a Mingmen pulse that is deep, fine, rapid, or deep, wiry, surging, large, and forceful; the Cunkou and Guankou pulses are similar. This is entirely due to Spleen and Stomach deficiency, with Qi sinking into the Kidney, combining with Ministerial Fire, causing Damp-Heat to press downward, resulting in continuous uterine bleeding. The blood color is purple-black, smelling like rotting meat in summer. If accompanied by leukorrhea (white vaginal discharge), the pulse must be wiry and fine, indicating cold within; if accompanied by bloody leukorrhea, the pulse is surging and rapid, clearly indicating heat, and there will inevitably be lower back pain extending to hypogastric pain. Before menstruation begins, chills and fever alternate, the bilateral flanks feel tight and contracted, and Spleen-Stomach symptoms appear, such as limb fatigue, mental restlessness, inability to sleep, and epigastric urgency. One should greatly tonify the Spleen and Stomach to regulate the ascending and descending of Qi and Blood, often achieving cure with a single dose. Alternatively, this condition, known as "Tuoying" (Depletion of Vitality), occurs when one's status changes from noble to base or rich to poor. Due to insufficient Heart Qi, Heart Fire blazes intensely within the blood vessels. Or, due to irregular diet damaging the Spleen and Stomach, Fire invades the Middle Jiao. Although the physical form, muscles, and complexion may appear healthy, this is actually a Heart disease manifesting in the pulse, making Spleen-Stomach dietary dysfunction obvious, leading to irregular menstruation, sudden cessation, or acute profuse bleeding. Treatment requires strong Qi and Blood tonification formulas to nourish the Spleen and Stomach, slightly adding herbs to suppress Heart Fire to treat the Heart. By nourishing Yin and draining Yang, menstruation will naturally cease. The *Treatise on Flaccidity* states: "Excessive grief severs the Bao Luo (uterine collaterals); when severed, Yang Qi moves internally, causing epigastric fullness and frequent hematuria." Thus it is said: "When the great vessels are empty, myofascial bi syndrome develops, transmitting to Mai Wei (pulse flaccidity)." This refers to such cases. The appropriate treatment is Shengyang Yiwetang (Ascending Yang and Benefit Stomach Decoction). Using Qi tonification for blood loss is an ancient method. First, tonify Stomach Qi to aid growth, hence "Yang generates Yin"; sweet-flavored herbs are the primary task.
Xue Lizhai said: Regarding metrorrhagia (sudden heavy uterine bleeding), the *Classic* states: "Yin deficiency with Yang pounding is called Beng." It also says: "Injury to Yang collaterals causes external blood overflow; injury to Yin collaterals causes internal blood overflow." Furthermore: "The Spleen controls blood, the Liver stores blood." Causes include: Spleen-Stomach deficiency failing to control blood return to its source; Liver channel fire causing blood to flow downward due to heat; Liver channel wind causing blood to act recklessly due to wind; anger stirring Liver fire causing blood to boil due to heat; Liver channel stagnation injuring blood preventing it from returning to its vessels; or anger stirring Liver fire/excessive grief injuring Bao Luo causing severe lower bleeding. Treatment methods: For Spleen-Stomach weakness, use Liujunzi Tang (Six Gentlemen Decoction) plus Chuanxiong, Danggui, Chaihu; for Spleen-Stomach sinking, use Buzhong Yiqi Tang (Tonify the Middle and Augment the Qi Decoction) plus Baishao, Zhizi; for Liver channel blood heat, use Siwu Tang (Four Substances Decoction) plus Chaihu, Zhizi, Fuling, Baizhu; for Liver channel wind-heat, use Jiawei Xiaoyao San (Modified Free and Easy Wanderer Powder) or Xiao Chaihu Tang (Minor Bupleurum Decoction) plus Zhizi, Baishao, Danpi; for anger-stirred Liver fire, use the previous prescriptions; for Spleen channel stagnant fire, use Guipi Tang (Restore the Spleen Decoction) plus Zhizi, Chaihu, Danpi; for grief-injured Bao Luo, use Sijunzi Tang (Four Gentlemen Decoction) plus Shengma, Chaihu, Zhizi. Thus, masters Dongyuan and Danxi stated: "For all lower bleeding syndromes, one must conclude treatment with Sijunzi Tang." This statement is profound. After massive blood loss, do not rely on pulse diagnosis; urgently use Dushen Tang (Single Ginseng Decoction) for rescue. Fever, cough, and rapid pulse indicate false heat due to deficient Yuan Qi; especially use Renshen (Ginseng Radix et Rhizoma). These syndromes invariably stem from prior Spleen-Stomach damage, presenting with surging pulses; if stomach Qi is present and can tolerate tonification, rescue is possible. Misusing cold-cooling drugs further damages Spleen-Stomach vital Qi, preventing blood control, accelerating danger.
Xue Lizhai Medical Cases:
A woman suffered from internal heat and thirst, reduced appetite, and a mass in the left abdomen growing from egg-sized to four cun. Menstruation occurred every three months. She was emaciated, with ulcer-like lesions on teeth and cheeks. Pulse was surging, rapid, and deficient, especially at Zuoguan. This was Liver-Spleen stagnation. Applied Awei Gao externally; took Buzhong Yiqi Tang in the morning and Jiawei Guipi Tang in the afternoon. After two months, Liver fire subsided, Spleen-Stomach remained robust. Continued previous decoctions with Liuwei Wan (Six Flavor Pill) in the morning, and Xiaoyao San with Guipi Wan in the afternoon. After another month, took Lulu Wan twice daily, with Xiaoyao San on an empty stomach and Guipi Tang in the evening. Due to careful regulation, she recovered after over a year.
Another woman had fever, dry mouth, irregular menstruation, and weak legs. After taking wind-dispelling and damp-draining drugs, she developed leg pain, fatigue, knee swelling, and amenorrhea. I diagnosed Spleen-Liver-Kidney blood deficiency with fire dryness, named Hexikfeng (Crane Knee Wind). Used Liuwei Wan and Bawei Wan concurrently for two months. Physical strength improved, appetite increased, knee swelling subsided, cured in less than half a year. If Spleen-Kidney deficiency-cold caused soft/painful legs or thin knees, use Bawei Wan. If overeating caused leg/buttock soreness or swelling, use Buzhong Yiqi Tang plus Fuling, Banxia.
A third woman was quiet, diligent in needlework, prone to anger, with a hypogastric mass causing pain or fullness and irregular menstruation. Strict use of Liver-suppressing drugs led to internal heat/chills, chest oppression, poor appetite, emaciation, and gum erosion. This indicated Spleen Earth failing to generate Lung Metal, Lung Metal failing to generate Kidney Water, and Kidney Water failing to generate Liver Wood. Nourish the source using Buzhong Yiqi Tang and Liuwei Dihuang Wan, curing by mid-spring.
He Gongren, Prefect of Songjiang, was irritable, with an abdominal mass for over a year, severely emaciated, mobile mass eroding the cheek. Some attributed it to Spring Wood overacting on Earth, advocating Liver suppression. In late winter, Liver pulse was surging-rapid, wiry-tight upon pressure, others weak. I said: "Surging-rapid-wiry-tight indicates true Liver Qi emerging while pathogenic Qi is excess; self-preservation is difficult, how can it suppress Earth? Green complexion hiding white indicates Kidney Water insufficiency, Liver Wood depletion, Lung Metal suppression; fear Wood cannot generate in Spring." Prescribed Spleen-strengthening and Kidney-nourishing herbs; after two doses, Liver pulse receded. Later, anger caused ear bleeding, pulse remained large but empty upon pressure, with irritability/thirst. This was rootless fire; added Rougui (Cinnamon Bark) to previous formula. After two doses, pulse敛 (contracted), heat/thirst retreated. Further anger caused anorexia; she died on Xin-Si day in late winter. Wood weakness facing Metal suppression proved true.
A fourth woman had delayed menstruation, fever, and fatigue. Use of Siwu Tang and Huanglian made menstruation occur only once every two months with scanty, clotted blood. Harsh purgatives blurred vision. I said: "Spleen is head of Yin, eyes are congregation of blood vessels. Spleen injury causes five Zang organs to lose support, failing to nourish eyes." Used Buzhong Yiqi Tang and Jisheng Guipi Tang, focusing on Spleen-Stomach, cured after over a year.
A fifth woman, aged 40, impatient, had indigestion and irregular menstruation. Qi-regulating/phlegm-resolving drugs caused abdominal distension and diarrhea. Adding Wuyao, Pengzhi worsened swelling and oliguria. Adding Zhuling, Zexie caused phlegm-wheezing and dyspnea. Cold limbs, facial/limb edema leaving pits on pressure, deep-fine pulse, prominent Youcun. I diagnosed Spleen-Lung Qi deficiency-cold failing to regulate water passages, leading to fluid retention ("mud in rain"). Prescribed Jin Gui Ji Jian Shenqi Wan material. Urination resumed, swelling halved, limbs warmed. Followed with Liujunzi Tang plus Muxiang, Rougui, Paojiang for full recovery. Relapse due to emotional/dietary indiscretion treated with previous formula plus Fuzi (Aconite Lateralis Radix Preparata).
A sixth woman had chronic dizziness and scanty/delayed menstruation. Diagnosed as Middle Qi deficiency failing to ascend (dizziness) and descend (scant menses). Cured with Buzhong Yiqi Tang. Later, exertion triggered flooding menses (Lao Shang Huo Dong). Previous formula plus Wuweizi cured immediately. Though described as blood loss causing Qi detachment, it was actually Lung Qi deficiency.
Qian Sizeng (Guest Teacher) stated: At 30, childless, with prolonged irregular bleeding, separated from wife for years, he sought to take a concubine. I said: "Depressive anger injured Liver, Spleen deficiency stirred fire, blood failed to return to vessels; Liver fails to store, Spleen fails to control. Clear Liver fire, tonify Spleen Qi." Prescribed Jiawei Guipi Tang and Xiaoyao San. Told his mother-in-law: "Medicine will cure her and enable conception; no concubine needed." She conceived and gave birth the next year.
A seventh woman, prone to anger, had menses stopping after days or half a month, progressing to prolonged spotting over three years. Emaciated, thirsty, internal heat, night sweats, worse afternoon fever. Used Renshen, Baizhu, Danggui, Fushen, Yuanzhi, Zaoren, Maidong, Wuweizi, Danpi, Longyanrou, Zhigancao, Chaihu, Shengma. Cured. Initial anger-stirred Liver fire caused reckless blood flow; later Spleen Qi sinking failed to control blood. If stomach heat consumed fluids causing amenorrhea, clear Stomach. If Heart fire excessive, clear Heart. If excessive dry herbs used, nourish Blood. If long-term Qi/Blood decline, strengthen Spleen-Stomach.
An eighth woman, irritable, postpartum lip swelling/internal heat, irregular menses, anorexia/vomiting, loose stools, lip bleeding. Qi-regulating/digestive aids caused chest fullness, unclear head/eyes, lip swelling/amenorrhea. Stomach-clearing/blood-invigorating aids caused fatigue, fever/irritability, salivation. Considering emmenagogues, I said: "Root is seven emotions, Liver-Spleen deficiency, repeated attacking weakened Yuan Qi. Tonify Yin/Yang." Used Jiawei Guipi Tang, Jiawei Xiaoyao San, Buzhong Yiqi Tang. Yuan Qi recovered, lip sores healed. Anger caused chills/ear pain/flank fullness/lip swelling; Liver fire injuring blood. Used Siwu Tang combined with Xiao Chaihu Tang plus Zhizi, cured instantly. Further anger caused flank/breast distension, abdominal pain, sour vomiting, anorexia, oliguria; Liver Wood suppressing Spleen Earth. Tonified Spleen Qi/Blood, cured. Exertion/anger/diet irregularity caused fever/wheezing/thirst/fatigue/anorexia, flooding hemorrhage, severe lip swelling; Liver fire, Spleen Qi deficiency. Used Buzhong Yiqi Tang plus Hei Zhizi, Danpi, Shaoyao, cured. Often, treating only sores without securing the root leads to death.
A ninth woman, 64, chronic anger, headache/chills-fever, spring breast pain. Liufei Yin worsened it, with intermittent bleeding. Great fright caused anorexia, insomnia, breast/flank swelling, burning pain, redness midday/afternoon. Diagnosed Liver-Spleen stagnant fire/blood dryness. Used Xiaoyao San plus Jiu Chao Hei Longdan (1 qian), Zhizi (0.5 qian). Two doses cleared it, two more eliminated it. Then Guipi Tang plus Chao Zhizi, Beimu, all symptoms retreated.
A tenth woman had anger-induced metrorrhagia, persistent, yellow-green complexion sometimes red. Liver Wood suppressing Spleen Earth causing blood deficiency. Used Xiao Chaihu Tang combined with Siwu Tang to clear Liver fire/generate Liver blood; then Guipi Tang and Buzhong Yiqi Tang to benefit Spleen Qi/generate Liver blood, cured. If Liver wind-heat caused restless blood, use Fangfeng pills with decoction for concurrent symptoms. If Liver fire movement caused restlessness, use Tiao Qin pills with decoction, always effective.
An eleventh woman, impatient, anger caused pain in ears/neck/throat/teeth/chest/breasts (if not Taiyang), chest fullness, acid regurgitation, vomiting/diarrhea, scanty food intake, continuous menstruation. All Liver fire syndromes. Liver self-disease shows exterior signs; Earth suppression shows interior signs. Liver self-disease: Siwu Tang plus Baizhu, Fuling, Chao Zhizi, Chao Longdan. Interior signs: Sijunzi Tang plus Chaihu, Baishao, Shenqu, Chao Lian (with Evodia). Symptoms gradually improved. Continuous menstruation indicated blood heat with Spleen deficiency. Used Xiaoyao San with doubled Baizhu, Fuling, Chenpi, plus Buzhong Yiqi Tang with Jiu Chao Shaoyao concurrently.
Gu Dahua's inner lady had irregular menstruation, metrorrhagia with fainting, fever, insomnia. Cold drugs worsened it; hemostatics for suspected pregnancy trauma failed. I said: "Spleen Qi deficiency failing to control blood. Tonify Spleen, blood stops." Used Buzhong Yiqi Tang plus Paojiang, effective quickly. Insomnia/panic persisted; family used Bazhen Tang, ineffective. I said: "Too mixed." Prescribed Guipi Tang plus Paojiang to tonify Heart/Kidney, restored health.
A twelfth woman had stomach fire, calmed by Qingwei San. Exertion caused dryness/thirst/internal heat, emaciation, amenorrhea. Stomach fire consumed Yin blood. Used Xiaoyao San plus Danpi, Chao Zhizi to clear Stomach heat; Bazhen Tang plus Fuling, Yuanzhi to nourish Spleen blood, menstruation resumed.
A thirteenth woman had exertion-induced tinnitus/headache/fatigue, Yuan Qi deficiency. Cured with Buzhong Yiqi Tang plus Maidong, Wuweizi. Three years later, diet/exertion worsened symptoms, amenorrhea, afternoon/internal heat, spontaneous/night sweats. Cured instantly with Liuwei Dihuang Wan and Buzhong Yiqi Tang. If blood deficiency with fire, use Siwu Tang plus Zhizi, Chaihu; if ineffective, Bazhen Tang plus previous herbs. If Qi deficiency, use Sijunzi Tang. If anger-induced deafness/tinnitus is excess, use Xiao Chaihu Tang plus Chuanxiong, Danggui, Zhizi; if deficiency, Buzhong Yiqi Tang plus Zhizi. If worse in morning (fire), use Xiao Chaihu Tang plus Chao Lian, Chao Zhizi; if Qi deficiency, Buzhong Yiqi Tang. If worse in afternoon (blood deficiency), use Siwu Tang plus Baizhu, Fuling. If Yin deficiency with fire movement or phlegm-thirst, use Dihuang Wan to strengthen Water master. *Classic* states: "Headache, tinnitus, nine orifices dysfunction arise from intestines/stomach." Spleen-Stomach deficiency affects ears, eyes, nine orifices.
*Treatment Outline* states: *Neijing* mentions Xueku (Blood Depletion) similar to Xuege (Blood Obstruction), both amenorrhea. However, Ku (depletion) and Ge (obstruction) are opposite, like ice and charcoal. Ku means exhaustion; Ge means blockage. Blood is not deficient, but Qi/Cold/Stagnation cause reversal, acute onset, painful/excess symptoms, requiring unblocking for blood flow and cure; this is attackable. Ku develops gradually, Spleen-Stomach Qi乏, Chong-Ren internal exhaustion, formless symptoms, absolutely not unblockable. Since blood is depleted, only nourish Yin to fill blood. Forced unblocking makes depletion worse, leading to danger.