经义
天地温和，则经水安静。天寒地冻，则经水凝泣。天暑地热，则经水沸溢。卒风暴起，则经水波涌而陇
起。夫邪之入于脉也，寒则血凝泣，暑则气淖泽。虚邪因而入客，亦如经水之得风也。○月事不来者，胞脉闭也。
胞脉者，属心而络于胞中。今气上迫肺，心气不得下通，故月事不来也。（《素问》）
冲脉起于胞中，出于气街，前行于胸，后行于背，上出颃颡，渗灌诸阳，下入于足，注诸络为十二经脉
之海。其出入皆少阴经以行，故为血海。（《灵枢》）
总论
凡看妇人病，入门先问经期。（寇宗 ）
冲为血海，诸经朝会。男子则运而行之，女子则停而止之。营运者，无积而不满，动也；停止者，有积
而能满，静也。不满者，阳也，气也；能满者，阴也，血也。故满者以时而溢，谓之信。男子以气运，故阳气
应日而举；女子以血满，故阴血应月而下。（《冯氏锦囊》）
任者妊也，属阴脉之海，此人生养之始也。督者都也，属阳脉之海，是人阳脉之都纲也。任脉主任一身
之阴血。太冲属阳明，为血之海。故谷气盛，则血海满，而月事以时下也。（程扶生）
饮食五味，养髓、骨、肉、血、肌肤、毛发。男子为阳，阳中有阴，阴数八，故一八而阳精升，二八而
阳精溢。女子为阴，阴中有阳，阳数七，故一七而阴血升，二七而阴血溢。皆饮食五
味之实秀也。○女人天癸既至，逾十年无男子合，则不调，未逾十年思男子合，亦不调，不调则旧血不出，新
血误行，或渍而入骨，或变而为肿。后虽合而难子。合多则沥枯虚人，产乳众则血枯杀人。观其精血，思过半
矣。○雌鸟牝兽无天癸而成胎者，鸟兽精血往来尾间也。（《褚氏遗书》）
《经》云∶女子二七天癸至。天癸者，阴精也。肾属水，癸亦属水，由先天之气蓄极而生，故谓阴精为天
癸。王冰以月事为天癸者，非也。男女之精，皆可以天癸称。今王注以女子之天癸为血，则男子之天癸亦为血
耶？男女当交媾之时，各有其精。而行经之际，方有其血。未闻交媾时可以血言也。至云∶精开裹血、血开裹
精者，亦非。《灵枢》云两神相搏，合而成形，常先身生，是谓精者，是也。但女子之精，以二七而至，而其
月事，亦与此时同其候也。（马元台）
妇人之于血也，经水蓄而为胞胎，则蓄者自蓄，生者自生。及其产育为恶露，则去者自去，生者自生。其
酝而为乳，则无复下漏而为月矣。失血为妄逆，产乳为常事，其去其生，则一同也。（滑伯仁）
女人之经，一月一行，其常也；或先或后，或通或塞，其病也。有行期只吐血、衄血，或眼耳出血者，是
谓倒经；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；有受胎数月，血忽大下，而胎不陨者，是谓漏胎。此虽以气血有余不足而言，
然亦异常矣。（李时珍）
经水者，阴血也。阴必从阳，故其色红，禀火色也。血为气之配，气热则热，气寒则寒，气升则升，气降
则降，气凝则凝，气滞则滞，气清则清，气浊则浊。成块者，气之凝也；将行而痛者，气之滞也；来后作痛者，
气血俱虚也；色淡者，亦虚也；错经妄行者，气之乱也；紫者，气之热也；黑者，热之甚也。人但见其紫黑作
痛成块者，率指为风冷，而投温热之剂，祸不旋踵矣！
或曰∶黑，北方水色也，非冷而何？予曰∶《经》曰亢则害，承乃制。热甚者，必兼水化。所以热则紫，甚则
黑也。（《格致余论》）
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，此分而四也。细详
之∶不调中有趱前者，有退后者，趱前为热，退后为虚也。不通中有血枯者，有血滞者，血滞宜破，血枯宜补
也。疼痛中有常时作痛者，有经前经后作痛者，常时与经前为血积，经后为血虚也。发热中有常时热者，有经
行发热者，常时为血虚有积，经行为血虚有热也。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，则恶露不净。此经候不调、不通、作痛、发热所由作也。大抵气行则
血行，气止则血止。故治血病，以行气为先。热则流通，寒则凝塞。故治血病，以热药为佐。（方约之）
妇人之病，当以经血为先。而血之所主，在古方书皆言心生血、肝藏血、脾统血。故凡伤心、伤脾、伤肝
者，均能为经脉之病。又曰∶肾为阴中之阴，肾主闭藏；肝为阴中之阳，肝主疏泄。二脏俱有相火，其系上属
于心。故心火一动，则相火翕然从之，多致血不静而妄行，此固一说。然相火动而妄行者有之，由火之盛也；
若中气脱陷，及门户不固而妄行者亦有之，此由脾肾之虚，不得尽言为火也。再如气道逆而不行者有之，由肝
之滞也；若精血败而不行者亦有之，此由真阴之枯竭，不得误以为滞也。是固心、脾、肝、肾四脏之病，而独
于肺脏多不言及，不知血之行与不行，无不由于气，故血脱者当益气，血滞者当调气。气主于肺，其义可知。
盖其病之肇端，则或由思虑，或由郁怒，或以积劳，或以六淫饮食，多起于心、肝、肺、脾四脏。及其甚也，
则四脏相移，必归脾肾。盖阳分日亏，则饮食日减，而脾气胃气竭矣；阴分日亏，则精血日涸，而冲任肾气竭
矣。故予曰∶阳邪之至，害必归阴；五脏之伤，穷必及肾。此源流之必然，即治病之要着。（张景岳）
调经莫先于去病。若潮热则血愈耗，呕咳则气上行，泻则津伤于后，痛则积结于中。若血滞渍入骨髓，便
为骨蒸；积瘀与新血相搏，则为疼痛；散于四肢，则麻木不仁；入于血室，则寒热不定。若血水相并，脾胃虚
弱，壅滞不通，变为水肿。（李 ）
脾气化液而生血，即水入于经，其血乃生之意。此营出中焦也，故曰生化之源。脾统血者，脾气化液入心
而变为血。故虽心之所主，亦赖脾气化生。此妇人经血不调，必审脾气化生之源，而健脾为调经之要也。（武叔卿）
或问∶论调经以滋水为主，不须补血，何也？曰∶夭者，天一之真。癸者，壬癸之水。月者，水之精，以
一月而盈，盈则昃。女人经水以时而下，故有子。不以时下，或过期，或不及，皆为病。所以必须调经，调经
必须滋水为主。又问曰∶同一红色，非血而何？曰∶人若有孕，则此水即以养胎，而不月矣。生子，则此水即
化为乳，亦不月矣。乳之色，白也，何谓血乎？论其至，则血亦水也，从乎火化而色赤；乳亦水也，从乎气化
而色白。况至七七而天癸绝，其所绝者，天癸水也；其流行之血，不见其枯涸，而仍行于经脉皮肤间也。故不
须四物补血，必以六味滋水。滋水可兼补血，补血兼不得滋水，何也？盖血乃后天饮食入胃，游溢精气而成。
若经水乃冲任所主。人身中有奇经八脉，冲任者奇经之二，为经脉之海，上为乳汁，下为月水。女人独禀此水
以为生生之原，与男子二八之精同气，俱从天一之源而来。冲任起于胞中，男子藏精，女子系胞，其间又恃一
点命门之火为之主宰。火旺则红，火衰则淡，火太旺则紫，火太衰则白。所以滋水更当养火。甚则干涸不通者，
虽曰火盛，实由水虚。亦不宜以苦寒降火，只宜补水，从天一之源以养之，使满则溢，万无有毒药可通之理。
此调经之法类如此。（赵养葵）
妇人属阴，以血为本，而有乳哺月经之耗，是以血病者多。夫月经者，津液血脉所成。苟营卫调和，经候
自然应期。苟气血一忤，则或先或后，多寡不匀，或闭绝不行而百病生。必须分因而治∶如真水亏败，阳火内
炽，血海枯竭，经绝不通者，宜补养阴血，则经自行；如寒客胞门子户，血泣不通，为 瘕之候者，宜散寒逐
瘀，则经自行矣。但血乃气之配，其升降、寒热、虚实，一从乎气。是以气热则血热而色紫；气寒则血寒而色
凝；气升则血逆而上出；气陷则血随而下崩。此调经莫先于养血，养血莫先于调气也。（汪石山）
妇人得阴柔之体，以血为本。阴血如水之行地，阳气若风之旋天。故风行则动，阳畅则血调。此自然之理
也。考古方耗气以调经，殊失其本。夫太冲者，气也。任脉者，血也。气升则升，气降则降，血随气行。若独
耗其气，血无所施，正气既虚，邪气必胜，而百病生焉。经安调乎？况心生血，脾统血，养其心则血生，实其
脾则血足。气胜则血行，安可独耗其气？此调经之至论也。（罗赤诚）
女科首重调经。经，常也。如潮之有信，如月之盈亏，不愆其期，故曰经水，又曰月信。《内经》云∶太
冲脉盛，月事以时下。景岳云∶冲为五脏六腑之海，脏腑之血，皆归冲脉。可见冲脉为月经之本也。然血气之
化，由于水谷，水谷盛则血气亦盛，水谷衰则血气亦衰。可见冲脉之血，又总由阳明水谷所化，而阳明胃气，
又为冲脉之本也。《经》曰∶二阳之病发心脾，有不得隐曲，女子不月。此虽言病发心脾，而实重在胃气。因
心为胃之母，胃为脾之腑也。《经》又曰∶有病胸胁支满者，妨于食，病至则先闻腥臊臭，出清液，先唾血，
四肢清，目眩，时时前后血，病名血枯。此得之年少时有所大脱血，若醉入房中，气竭肝伤，故月事衰少不来
也。此段经文，全重在"气竭肝伤"四字，为通节之纲旨。《金匮》言调经之法甚详，后世如王节斋、薛立斋诸
贤，论证透彻，用方精切，俱可以为程序。今观叶案，奇经八脉，固属扼要，其次最重调肝。因女子以肝为先
天，阴性凝结，易于拂郁，郁则气滞，而血亦滞。木病必妨土，故次重脾胃。余则血虚者养之，血热者凉之，
血瘀者通之，气滞者疏之，气弱者补之。诚女科之明鉴。（《临证指南》）
经期不调
经行每月一至，如潮之信。若每月既至，或三日，或四、五日即应止。而复淋漓不断者，非冲任气虚，不
能约束，为内伤不足；即劳伤气血，邪客胞门，为外感有余。当参以人之强弱也。○妇人有因病而后致经不调者，
有因经不调而后生病者。如因病而后经不调，当先治病，病去则经自调；若因经不调而后生病，当先调经，经
调则病自除。（萧慎斋）
经以月至，常也。其来过与不及，皆谓之病。若营血亏损，不能滋养百骸，则发落面黄，羸瘦燥热。燥气
盛则金受邪，金受邪则为咳嗽、为肺痈、为肺痿必矣。但助胃壮气，则营血生，而经自行。若果因气逆，经闭
不行，当用行气破血之剂。（初虞世）
丹溪曰∶先期而至者，血热也；后期而至者，血虚也。窃谓先期而至，有因脾经血燥者；有因脾经郁滞者；
有因肝经怒火者；有因血分有热者；有因劳役动火者。过期而至，有因脾经血虚者；有因肝经血少者；有因气
虚血弱者。主治之法∶脾经血燥者，加味逍遥散；脾经郁滞者，加味归脾汤；肝经怒火者，加味小柴胡汤；血
分有热者，加味四物汤；劳役动火者，补中益气汤。其过期而至，若脾经血虚者，人参养营汤；肝经血少者，
六味地黄丸；气虚血弱者，八珍汤。盖血生于脾，故云脾统血。凡血病当用苦甘之剂，以助其阳气而生阴血也。
（薛立斋）
先期而至，虽曰有火，若虚而挟火，则所重在虚，当以养营安血为主。然亦有无火而先期者，则或补中气，
或固命门，皆不宜过用寒凉也。后期而至，本属血虚，然亦有血热者，不得不为
清补；有血逆者，不得不为疏利。总之，调经之法，但欲得其和平，在详察其脉证耳。若形气脉气俱有余，方
可用清、用利。然虚者多，实者少。故调经之要，贵在补脾胃以资血之源，养肾气以安血之室。知斯二者，则
尽善矣。○经早者当以每月大概论，血热者当以通身藏象论。勿以素多不调，而偶见先期者为早；勿以脉证无
火，而单见经早者为热。○若一月二、三至，或半月、旬日而至者，此血气败乱之证，当因其寒热而调治之，
不得以经早者业论。（张景岳）
经期不通
妇人经水不利下，抵当汤主之。○妇人经水闭不利，脏坚癖不止，中有干血，下白物，矾石丸主之。（《金匮》）
妇人经水不利下，言经行不通利快畅下也。乃妇人恒有之病，不过活瘀导气，调和冲任，足以愈之。今曰
抵当汤主之。夫抵当重剂，文内并无少腹结痛、大便黑、小便利、发狂、善忘、寒热等证，恐药重病轻，必有
残缺错简，读者审之。○脏，阴内也，不止不去也。经水闭而不通，瘀宿血也。阴中坚块不去，血干凝也。下白
物，化血成带也。用矾石丸坐药治之。此方治下白物，若从湿化者可也，恐未能攻坚癖、干血也。（《医宗金鉴》）
妇人经闭不行，有因脾胃久虚，形体羸弱，气血俱衰，以致经水断绝者；有因劳心过度，心火上行，不得
下通胞脉，是以月事不来者；有因中消，胃热善饥，肌肉消瘦，津液不升，血海枯竭，名曰血枯经绝者；有因
【经义】
天地气候温和，则女子月经安静正常。天气严寒、大地冰冻，则月经凝滞不畅。天气暑热、地气炎热，则月经沸腾外溢。突然狂风大作，则月经如波浪涌起般紊乱。邪气侵入血脉，遇寒则血液凝滞，遇暑则气血濡润。虚邪趁机侵入人体，也如同经水遇到风一样受到影响。○月经不来，是因为胞脉闭塞。胞脉，归属于心并联络于胞宫（子宫）。如今气机上逆逼迫肺脏，心气不能下行通达，所以月经不来。（《素问》）
冲脉起于胞中，出于气街穴，前行于胸部，后行于背部，向上出于咽喉部，渗灌诸阳经，向下进入足部，注入各络脉，是十二经脉的海汇之处。它的运行都伴随少阴经进行，所以被称为血海。（《灵枢》）
【总论】
凡是诊治妇科病，进门先要询问月经情况。（寇宗奭）
冲脉是血海，各条经脉在此朝会。男子则是推动运行它，女子则是停留蓄积它。运行者，没有积聚而不满，属于动；停止蓄积者，有积聚而能充满，属于静。不满者，属阳，指气；能充满者，属阴，指血。所以充满时按时溢出，称为“信”（定期）。男子以气运化，所以阳气应日而勃起；女子以血充满，所以阴血应月而下潮。（《冯氏锦囊》）
任脉即“妊”，属于阴脉之海，这是人生养育的起始。督脉即“都”，属于阳脉之海，是人体阳脉的总纲。任脉主管一身之阴血。太冲脉隶属于阳明胃经，为血之海。所以谷气旺盛，则血海充盈，月经就能按时来潮。（程扶生）
饮食的五味，滋养骨髓、肌肉、血液、肌肤、毛发。男子属阳，阳中有阴，阴数用八计算，所以一八岁（八岁）时阳精上升，二八岁（十六岁）时阳精溢泄。女子属阴，阴中有阳，阳数用七计算，所以一七岁（七岁）时阴血上升，二七岁（十四岁）时阴血溢泄。这都是饮食五味精华的作用。○女人天癸（促进生殖功能成熟的物质）既已到来，超过十年没有与男子交合，则月经不调；未满十年就想与男子交合，也会月经不调。月经不调则旧血排不出，新血误行，有的渗入骨中，有的变为肿胀。后来即使交合也难以受孕。交合过多则耗竭精气使人体虚弱，生育哺乳多则血枯致死。观察其精血的变化，道理就明白大半了。○雌鸟和母兽没有天癸却能受孕，是因为鸟兽的精血往来于尾闾部位。（《褚氏遗书》）
《内经》说：女子二七岁（十四岁）天癸至。天癸，就是阴精。肾属水，癸也属水，由先天之气蓄积至极而生发，所以称阴精为天癸。王冰将月事称为天癸，是不对的。男女的精华，都可以称为天癸。现在王冰注解说女子的天癸是血，那么男子的天癸也是血吗？男女在交媾之时，各自有其精。而在行经之际，才有其血。没听说过交媾时可以用血来说明的。至于说“精开裹血、血开裹精”的说法，也不对。《灵枢》说两神相搏，结合而成形，常在身体形成之前产生，这叫做精，这才是正确的。只是女子的精，在二七岁时到来，而其月经，也在这个时候出现同样的征候。（马元台）
妇人对于血而言，经血蓄积成为胞胎的基础，则蓄积的自蓄积，生成的自生成。等到分娩产出恶露，则离去的自离去，生成的自生成。酝酿成为乳汁，就不再向下漏出成为月经了。失血导致妄逆，产乳是常事，它们离去和生成的规律，是一样的。（滑伯仁）
女人的月经，一个月来一次，这是常态；或提前或推后，或通畅或闭塞，这是病态。有的在行经期只出现吐血、鼻出血，或眼耳出血的，这叫倒经；有的三个月来一次的，这叫居经；有的一年来一次的，这叫避年；有的终身不来月经却能受孕的，这叫暗经；有的受孕之后，每月仍行经但生下孩子的，这叫胎盛；有的受孕数月，血突然大量下流但胎儿不堕落的，这叫漏胎。这些虽然是用气血有余不足来解释，但也属于异常情况。（李时珍）
经水，是阴血。阴必从阳，所以颜色红，禀受火的色泽。血是气的配偶，气热则血热，气寒则血寒，气升则血升，气降则血降，气凝则血凝，气滞则血滞，气清则血清，气浊则血浊。成块的，是气凝所致；将要行经时疼痛的，是气滞所致；行经后疼痛的，是气血俱虚；颜色淡的，也是虚；错经妄行的，是气乱；颜色紫的，是气热；颜色黑的，是热极。人们只见其紫黑作痛成块，通常指为风冷，而投用温热药，灾祸立刻就会降临！
有人说：黑色，是北方水的颜色，不是寒冷是什么？我说：《内经》说亢盛则有害，承制才能平衡。热极盛的，必然兼有水化。所以热则色紫，极热则色黑。（《格致余论》）
妇人的经病，有月经失调的，有月经不通的。然而在不调和不通中，又有兼疼痛的，兼发热的，这样分为四类。仔细详查：不调中有提前的，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。疼痛中有平时作痛的，有经前经后作痛的，平时和经前作痛为血积，经后作痛为血虚。发热中有平时发热的，有行经时发热的，平时发热为血虚有积，行经发热为血虚有热。在这四者之中，又细分为八种。人的气血周流全身，忽然有忧思愤怒，则郁结不行。经前产后，忽然遇到饮冷受寒，则恶露不净。这就是经候不调、不通、作痛、发热产生的原因。大致气行则血行，气止则血止。所以治血病，以行气为先。热则流通，寒则凝塞。所以治血病，以热药为辅助。（方约之）
妇人的病，应当以经血为首要关注。而血的主宰，在古代方书中都说心生血、肝藏血、脾统血。所以凡是伤心、伤脾、伤肝的，都能导致经脉疾病。又说：肾为阴中之阴，肾主闭藏；肝为阴中之阳，肝主疏泄。这两脏都有相火，其联系上属于心。所以心火一动，相火就随之翕然发动，多导致血不宁静而妄行，这固然是其中一种说法。然而相火动而妄行的确有，这是由于火盛；若中气下陷脱失，以及门户不固而妄行的也有，这是由于脾肾之虚，不能全说是火。再如气道逆乱不行的有，是由于肝之滞涩；若精血败坏不行的也有，这是由于真阴枯竭，不能误认为是滞涩。这确实是心、脾、肝、肾四脏的病，却唯独很少提及肺脏，不知道血的行与不行，无不由于气，所以血脱者当益气，血滞者当调气。气主司于肺，其中的道理可知。大概病的起因，或许由于思虑，或许由于郁怒，或许由于积劳，或许由于六淫饮食，多起于心、肝、肺、脾四脏。等到病情严重，则四脏相互传变，必定归于脾肾。因为阳分日渐亏损，则饮食日渐减少，脾气胃气衰竭；阴分日渐亏损，则精血日渐枯竭，冲任肾气衰竭。所以我说道：阳邪侵袭，危害必归于阴；五脏受伤，穷尽必及于肾。这是源流的必然规律，也是治病的关键要点。（张景岳）
调理月经莫先于去除疾病。如果有潮热则血更耗损，呕咳则气上行，腹泻则津液损伤于后，疼痛则积结于中。如果血滞渍入骨髓，就成为骨蒸；瘀积与新血相搏，就成为疼痛；散于四肢，则麻木不仁；进入血室，则寒热不定。如果血水相并，脾胃虚弱，壅滞不通，变为水肿。（李梴）
脾气化生津液而生血，就是水进入经脉，血液才生成的意思。这就是营气出于中焦，所以称为生化之源。脾统血，是指脾气化液入心而变为血。所以虽然是心所主宰，也依赖脾气化生。因此妇人经血不调，必须审察脾气化生的源头，而健脾是调经的关键。（武叔卿）
有人问：论述调经以滋水为主，不需要补血，为什么？答：夭，是天一的真气。癸，是壬癸之水。月，是水的精华，因一月而盈满，盈满则亏缺。女人经水按时而下，所以能生子。如果不按时而下，或过期，或不及，都是病。所以必须调经，调经必须以滋水为主。又问：同样是红色，不是血是什么？答：人若有孕，则此水即以养胎，就不来月经了。生子后，此水即化为乳，也不来月经了。乳的颜色是白色的，怎么能说是血呢？论其极致，血也是水，随火化而色赤；乳也是水，随气化而色白。况且到了七七四十九岁天癸绝，所绝的是天癸水；其流行之血，不见其枯竭，仍然行于经脉皮肤间。所以不需要用四物汤补血，必须用六味地黄丸滋水。滋水可以兼补血，补血兼不得滋水，为什么？盖血乃后天饮食入胃，游溢精气而成。若经水是冲任所主。人身中有奇经八脉，冲任是奇经之二，为经脉之海，上为乳汁，下为月水。女人独禀此水以为生生之源，与男子二八之精同气，都从天一之源而来。冲任起于胞中，男子藏精，女子系胞，其间又恃一点命门之火为之主宰。火旺则红，火衰则淡，火太旺则紫，火太衰则白。所以滋水更当养火。甚至干涸不通的，虽说火盛，实由水虚。也不宜用苦寒降火，只宜补水，从天一之源来滋养，使满则溢，万无有毒药可通之理。这就是调经的大致方法。（赵献可）
妇人属阴，以血为本，而有乳哺月经的消耗，所以血病者多。夫月经，是津液血脉所成。如果营卫调和，经候自然应期。如果气血一逆乱，则或提前或推后，多少不匀，或闭绝不行而百病生。必须分病因治疗：如真水亏败，阳火内炽，血海枯竭，经绝不通的，宜补养阴血，则经自行；如寒邪客于胞门子户，血凝泣不通，形成瘕聚的，宜散寒逐瘀，则经自行矣。但血是气的配偶，其升降、寒热、虚实，完全听从于气。所以气热则血热而色紫；气寒则血寒而色凝；气升则血逆而上出；气陷则血随而下崩。这是调经莫先于养血，养血莫先于调气。（汪机）
妇人得阴柔之体，以血为本。阴血如水之行于地，阳气若风之旋于天。所以风行则动，阳畅则血调。这是自然的道理。考察古方耗气以调经，殊失其根本。夫太冲脉，是气。任脉，是血。气升则升，气降则降，血随气行。如果独耗其气，血无所施，正气既虚，邪气必胜，而百病生焉。经怎么调呢？况且心生血，脾统血，养其心则血生，实其脾则血足。气胜则血行，怎么可以独耗其气？这是调经的最高理论。（罗赤诚）
女科首重调经。经，是常的意思。如潮汐有信，如月亮盈亏，不延误其期限，所以叫经水，又叫月信。《内经》说：太冲脉盛，月事以时下。张景岳说：冲为五脏六腑之海，脏腑之血，皆归冲脉。可见冲脉为月经之本。然而血气的化生，由于水谷，水谷盛则血气亦盛，水谷衰则血气亦衰。可见冲脉之血，又总由阳明水谷所化，而阳明胃气，又为冲脉之本。《内经》说：二阳之病发心脾，有不得隐曲，女子不月。这虽然说是病发心脾，而实际重在胃气。因为心为胃之母，胃为脾之腑。《内经》又说：有病胸胁支满者，妨于食，病至则先闻腥臊臭，出清液，先唾血，四肢清，目眩，时时前后血，病名血枯。这是得于年少时有所大脱血，或醉后入房，气竭肝伤，所以月事衰少不来也。这段经文，全重在“气竭肝伤”四字，为通节之纲旨。《金匮要略》言调经之法甚详，后世如王节斋、薛立斋诸位贤人，论证透彻，用方精切，都可以作为准则。现在看叶天士医案，奇经八脉，固属扼要，其次最重调肝。因为女子以肝为先天，阴性凝结，易于拂郁，郁则气滞，而血亦滞。木病必妨土，故次重脾胃。其余血虚者养之，血热者凉之，血瘀者通之，气滞者疏之，气弱者补之。真是女科的明鉴。（《临证指南医案》）
【经期不调】
经行每月一至，如潮汐之有信。如果每月既至，或三日，或四、五日即应止，而复淋漓不断者，非冲任气虚，不能约束，为内伤不足；即是劳伤气血，邪客胞门，为外感有余。应当参酌病人的强弱。○妇人有因病而后致经不调者，有因经不调而后生病者。如因病而后经不调，当先治病，病去则经自调；若因经不调而后生病，当先调经，经调则病自除。（萧慎斋）
经以月至，是常态。其来过早或过晚，都称为病。如果营血亏损，不能滋养百骸，则发落面黄，羸瘦燥热。燥气盛则金受邪，金受邪则为咳嗽、为肺痈、为肺痿必矣。只要助胃壮气，则营血生，而经自行。如果果因气逆，经闭不行，当用行气破血之剂。（初虞世）
朱丹溪说：先期而至者，血热也；后期而至者，血虚也。我认为先期而至，有因脾经血燥者；有因脾经郁滞者；有因肝经怒火者；有因血分有热者；有因劳役动火者。过期而至，有因脾经血虚者；有因肝经血少者；有因气虚血弱者。主治之法：脾经血燥者，加味逍遥散；脾经郁滞者，加味归脾汤；肝经怒火者，加味小柴胡汤；血分有热者，加味四物汤；劳役动火者，补中益气汤。其过期而至，若脾经血虚者，人参养营汤；肝经血少者，六味地黄丸；气虚血弱者，八珍汤。盖血生于脾，所以说脾统血。凡血病当用苦甘之剂，以助其阳气而生阴血也。（薛己）
先期而至，虽曰有火，若虚而挟火，则所重在虚，当以养营安血为主。然而也有无火而先期的，则或补中气，或固命门，都不宜过用寒凉。后期而至，本属血虚，然而也有血热者，不得不为清补；有血逆者，不得不为疏利。总之，调经之法，但欲得其和平，在详察其脉证耳。如果形气脉气俱有余，方才可用清、用利。然而虚者多，实者少。所以调经的要领，贵在补脾胃以资血之源，养肾气以安血之室。知此二者，则尽善矣。○经早者当以每月大概论，血热者当以通身藏象论。不要以素多不调，而偶见先期者为早；不要以脉证无火，而单见经早者为热。○如果一月二、三至，或半月、旬日而至者，这是血气败乱之证，应当因其寒热而调治之，不得以经早者一概而论。（张景岳）
【经期不通】
妇人经水不利下，抵当汤主之。○妇人经水闭不利，脏坚癖不止，中有干血，下白物，矾石丸主之。（《金匮要略》）
妇人经水不利下，是说经行不通利快畅下也。乃是妇人恒有之病，不过是活瘀导气，调和冲任，足以愈之。今曰抵当汤主之。夫抵当为重剂，文内并无少腹结痛、大便黑、小便利、发狂、善忘、寒热等证，恐药重病轻，必有残缺错简，读者审之。○脏，指阴内也，不止不去也。经水闭而不通，瘀宿血也。阴中坚块不去，血干凝也。下白物，化血成带也。用矾石丸坐药治之。此方治下白物，若从湿化者可也，恐未能攻坚癖、干血也。（《医宗金鉴》）
妇人经闭不行，有因脾胃久虚，形体羸弱，气血俱衰，以致经水断绝者；有因劳心过度，心火上行，不得下通胞脉，是以月事不来者；有因中消，胃热善饥，肌肉消瘦，津液不升，血海枯竭，名曰血枯经绝者；有因
[Scriptural Principles]
When the climate of heaven and earth is mild and warm, the menstrual water remains calm and regular. When the weather is severely cold and the earth frozen, the menstrual water becomes stagnant and sluggish. When the weather is hot and the earth heat rises, the menstrual water boils and overflows. When a sudden storm arises, the menstrual water surges like waves. When pathogenic factors enter the vessels, cold causes blood to coagulate and stagnate, while heat makes qi and blood moist and fluid. Deficient pathogens taking advantage to invade the body are also like menstrual water affected by wind. ○ When menstruation does not occur, it is due to the closure of the Bao Mai (uterine vessels). The Bao Mai belongs to the Heart and connects to the Bao Zhong (uterus). Now, if Qi ascends and presses upon the Lung, the Heart Qi cannot descend and communicate, thus menstruation does not occur. (*Su Wen*)
The Chong Mai (Penetrating Vessel) originates from the Bao Zhong, emerges at the Qijie point, moves forward in the chest, and backward along the back, emerging upward at the Hangsang (pharynx), seeping into and irrigating the Yang meridians, descending into the feet, and pouring into the collateral vessels; it is the Sea of the Twelve Meridians. Its movement follows the Shaoyin Meridian, hence it is called the Sea of Blood. (*Ling Shu*)
[General Discussion]
In treating gynecological diseases, one must first inquire about the menstrual cycle upon entering. (Kou Zongshi)
The Chong Mai is the Sea of Blood, where all meridians converge. In men, it is moved and circulated; in women, it is stopped and accumulated. Movement implies no accumulation and fullness, which is dynamic; stopping and accumulating implies fullness, which is static. Lack of fullness belongs to Yang, which is Qi; ability to fill belongs to Yin, which is Blood. Therefore, when full, it overflows on schedule, termed "Xin" (trust/regularity). Men rely on Qi for circulation, so Yang Qi responds to the day and rises; women rely on Blood for fullness, so Yin Blood responds to the month and descends. (*Feng Shi Jin Nang*)
Ren Mai (Conception Vessel) means "pregnancy"; it is the Sea of Yin Meridians, marking the beginning of human reproduction. Du Mai (Governing Vessel) means "capital"; it is the Sea of Yang Meridians, serving as the chief outline of the body's Yang meridians. The Ren Mai governs the Yin Blood of the whole body. The Taichong Mai belongs to the Yangming Stomach Meridian and is the Sea of Blood. Thus, when Gu Qi (Grain Qi) is abundant, the Sea of Blood fills, and menstruation occurs on time. (Cheng Fusheng)
The five flavors of food nourish marrow, bones, flesh, blood, skin, hair, and nails. Men belong to Yang, containing Yin within Yang; the number for Yin is eight. Thus, at age eight (1x8), Yang Essence rises; at age sixteen (2x8), Yang Essence overflows. Women belong to Yin, containing Yang within Yin; the number for Yang is seven. Thus, at age seven (1x7), Yin Blood rises; at age fourteen (2x7), Yin Blood overflows. All this results from the essence of the five flavors of food. ○ Once Tian Gui (menstrual essence/reproductive maturity) arrives in women, if there is no intercourse with men for over ten years, menstruation will be irregular; if intercourse is desired before ten years have passed, menstruation will also be irregular. Irregular menstruation means old blood does not exit, and new blood flows erroneously, sometimes soaking into bones or turning into swelling. Even if intercourse occurs later, conception may be difficult. Excessive intercourse depletes Jing and Blood, causing weakness; excessive childbirth and lactation deplete Blood, potentially leading to death. Observing their Jing and Blood reveals half the truth. ○ Female birds and animals lack Tian Gui yet conceive because their Jing and Blood circulate through the Weijian area. (*Chu Shi Yi Shu*)
The Classics state: At age fourteen (2x7), Tian Gui arrives in women. Tian Gui is Yin Essence. The Kidney belongs to Water, and Gui also belongs to Water; it is generated when Pre-heaven Qi accumulates to its extreme, hence Yin Essence is called Tian Gui. Wang Bing’s interpretation that menstruation is Tian Gui is incorrect. The essence of both men and women can be called Tian Gui. If Wang Bing’s annotation states that women’s Tian Gui is Blood, is men’s Tian Gui also Blood? During intercourse, each has their respective Jing. During menstruation, there is Blood. It is unheard of to refer to intercourse in terms of Blood. The statement that "Jing opens to wrap Blood, Blood opens to wrap Jing" is also incorrect. *Ling Shu* states: "When two spirits interact, they combine to form shape, often existing before the body, this is called Jing," which is correct. However, women’s Jing arrives at age fourteen, and their menstruation appears at the same time. (Ma Yuantai)
Regarding women and Blood: Menstrual blood accumulates to form the basis of the fetus; what accumulates accumulates, what generates generates. Upon childbirth, lochia exits; what leaves leaves, what generates generates. When fermented into milk, it no longer leaks downward as menstruation. Hemorrhage causing rebellion is abnormal, while childbirth and lactation are normal; their leaving and generating follow similar principles. (Hua Borén)
Women’s menstruation occurring once a month is normal; early or late, patent or obstructed, are pathological. Some experience only hematemesis, epistaxis, or bleeding from eyes/ears during the period, called Dao Jing (Reverse Menstruation); some menstruate once every three months, called Ju Jing; once a year, called Bi Nian; never menstruating but conceiving, called An Jing; menstruating monthly after conception but delivering a child, called Tai Sheng; heavy bleeding several months into pregnancy without miscarriage, called Lou Tai. Although explained by excess or deficiency of Qi and Blood, these are abnormal. (Li Shizhen)
Menstrual water is Yin Blood. Yin must follow Yang, hence its red color, inheriting the hue of Fire. Blood is the companion of Qi; if Qi is hot, Blood is hot; if Qi is cold, Blood is cold; if Qi ascends, Blood ascends; if Qi descends, Blood descends; if Qi coagulates, Blood coagulates; if Qi stagnates, Blood stagnates; if Qi is clear, Blood is clear; if Qi is turbid, Blood is turbid. Clots indicate Qi coagulation; pain before flow indicates Qi stagnation; pain after flow indicates Qi and Blood deficiency; pale color indicates deficiency; erratic flow indicates Qi chaos; purple color indicates Qi heat; black color indicates extreme heat. People seeing purple-black clots and pain usually attribute it to Wind-Cold and prescribe warming agents, bringing disaster swiftly!
One might say: Black is the color of Water in the North, surely cold? I say: The Classic states, "Excess brings harm, control brings balance." Extreme heat must incorporate Water transformation. Hence heat yields purple, extreme heat yields black. (*Ge Zhi Yu Lun*)
Gynecological menstrual disorders include irregular cycles and obstructed cycles. Among these, some involve pain, some involve fever, dividing them into four categories. Detailed analysis: Irregularity includes advancement (early) and retardation (late); advancement is Heat, retardation is Deficiency. Obstruction includes Blood Dryness and Blood Stasis; Stasis requires breaking, Dryness 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 circulate constantly; sudden worry, thought, or anger causes stagnation. Before or after menstruation, sudden cold drinks or exposure cause lochia retention. This is the origin of irregular, obstructed, painful, and febrile menstruation. Generally, Qi movement drives Blood movement; Qi cessation stops Blood. Thus, treating Blood disorders prioritizes moving Qi. Heat promotes flow, Cold causes obstruction. Thus, treating Blood disorders uses warming herbs as assistants. (Fang Yue Zhi)
Gynecological diseases should prioritize menstrual blood. Ancient texts state the Heart generates Blood, Liver stores Blood, Spleen controls Blood. Thus, injury to Heart, Spleen, or Liver can cause menstrual disease. It is said: Kidney is Yin within Yin, governing storage; Liver is Yang within Yin, governing dispersion. Both contain Ministerial Fire, connecting upward to the Heart. Thus, when Heart Fire moves, Ministerial Fire follows, often causing Blood to move recklessly. This is one view. However, reckless movement due to Ministerial Fire exists due to Fire excess; movement due to sinking of Middle Qi or insecure gates exists due to Spleen/Kidney deficiency, not solely Fire. Also, reverse Qi flow causing obstruction exists due to Liver stagnation; exhaustion of Jing/Blood causing obstruction exists due to True Yin depletion, not merely stagnation. These are diseases of Heart, Spleen, Liver, Kidney, yet rarely mention Lung. Unknown to many, Blood movement depends on Qi; thus, Blood loss requires tonifying Qi, Blood stasis requires regulating Qi. Qi is governed by Lung, revealing the principle. Disease origins often stem from worry, anger, fatigue, or Six Evils/Diet, affecting Heart, Liver, Lung, Spleen. Severe cases transfer among these four, ultimately returning to Spleen/Kidney. Daily decline of Yang reduces diet, exhausting Spleen/Stomach Qi; daily decline of Yin dries Jing/Blood, exhausting Chong/Ren/Kidney Qi. Thus, I say: Yang pathogens harm Yin; Five Zang injuries reach Kidney. This is the inevitable source and key to treatment. (Zhang Jingyue)
Regulating menstruation begins with removing disease. Tidal fever consumes Blood; vomiting/coughing raises Qi; diarrhea injures fluids; pain creates internal accumulation. If Blood stagnation soaks into marrow, it becomes bone-steaming fever; stasis fighting new blood causes pain; dispersing to limbs causes numbness; entering Blood Chamber causes alternating chills/fever. If Blood and Water merge with weak Spleen/Stomach, obstruction leads to edema. (Li Chan)
Spleen Qi transforms fluids to generate Blood; this is the meaning of water entering vessels to create Blood. This is Ying Qi originating from Middle Jiao, hence called the Source of Generation and Transformation. Spleen controls Blood by transforming fluids into Heart Blood. Thus, although Heart governs, it relies on Spleen Qi. Therefore, for irregular menstruation, one must examine the Spleen’s generation source; strengthening Spleen is key to regulating menstruation. (Wu Shuqing)
Question: Why regulate menstruation by nourishing Water rather than tonifying Blood? Answer: Yao refers to the true Qi of Tian Yi. Gui refers to the Water of Ren/Gui. Moon is the essence of Water, filling monthly; fullness leads to waning. Women’s menstruation comes on time, enabling conception. If not on time, early or late, it is disease. Thus, regulation is necessary, primarily by nourishing Water. Question: It is red, isn't it Blood? Answer: With pregnancy, this Water nourishes the fetus, stopping menstruation. After birth, this Water transforms into milk, stopping menstruation. Milk is white, how is it Blood? Ultimately, Blood is Water, transformed by Fire to be red; Milk is Water, transformed by Qi to be white. Moreover, at age 49 (7x7), Tian Gui ceases; what ceases is Tian Gui Water; circulating Blood does not dry up but continues in vessels/skin. Thus, Si Wu Tang (Blood Tonification) is unnecessary; Liu Wei Di Huang Wan (Water Nourishment) is required. Nourishing Water can tonify Blood, but tonifying Blood cannot replace nourishing Water. Why? Blood is formed from post-natal diet in Stomach. Menstrual water is governed by Chong/Ren. Among Eight Extraordinary Vessels, Chong/Ren are the Sea of Meridians, upper milk, lower menses. Women uniquely possess this Water as the source of life, same Qi as men’s Jing at age 16, both from Tian Yi source. Chong/Ren originate in Bao Zhong; men store Jing, women connect to Bao, governed by Mingmen Fire. Fire strong = red; Fire weak = pale; Fire very strong = purple; Fire very weak = white. Thus, nourishing Water must nurture Fire. Even if dry/obstructed, though seemingly Fire excess, it is actually Water deficiency. Bitter-cold fire-draining is unsuitable; only tonifying Water from Tian Yi source is appropriate, making it full then overflowing. No toxic drugs should be used to force flow. This is the general method of regulating menstruation. (Zhao Yangkui)
Women belong to Yin, using Blood as root, suffering consumption from lactation/menstruation, hence many Blood diseases. Menstruation is formed from Jin Ye (fluids) and Blood vessels. If Ying/Wei harmonize, periods are regular. If Qi/Blood clash, timing varies, volume uneven, or amenorrhea with myriad diseases. Must treat based on cause: If True Water deficient, Internal Fire blazing, Sea of Blood exhausted, amenorrhea occurs; tonify Yin/Blood, menstruation returns. If Cold invades Bao Men/Zi Hu, Blood stagnates, forming masses; disperse Cold/remove Stasis, menstruation returns. Blood is Qi’s companion; its ascent/descent, cold/heat, deficiency/excess follow Qi. Qi hot = Blood hot/purple; Qi cold = Blood cold/coagulated; Qi ascending = Blood reversing/upward; Qi sinking = Blood collapsing/downward. Thus, regulating menstruation prioritizes nourishing Blood; nourishing Blood prioritizes regulating Qi. (Wang Shishan)
Women have Yin-soft bodies, using Blood as root. Yin Blood is like water flowing on earth; Yang Qi is like wind rotating in sky. Wind moves, Yang flows, Blood regulates. This is natural law. Ancient methods耗气 (depleting Qi) to regulate menstruation lose the root. Taichong is Qi; Ren Mai is Blood. Qi ascends/descends, Blood follows Qi. Depleting Qi alone leaves Blood无处施 (nowhere to act); Zheng Qi weak, Xie Qi wins, diseases arise. How can menstruation be regulated? Heart generates Blood, Spleen controls Blood; nourish Heart, Blood generates; strengthen Spleen, Blood suffices. Qi strong, Blood moves; why deplete Qi alone? This is the supreme theory of regulating menstruation. (Luo Chicheng)
Gynecology prioritizes regulating menstruation. Jing means constancy, like tides’ trust, like moon’s wax/wane, not missing its date, hence Jing Shui or Yue Xin. *Nei Jing* says: Taichong Mai vigorous, menstruation on time. Jingyue says: Chong is Sea of Five Zang/Six Fu, Blood of Zang/Fu returns to Chong. Thus Chong is root of menstruation. However, Blood/Qi transformation comes from Grain/Water; Grain/Water abundant, Blood/Qi abundant; Grain/Water scarce, Blood/Qi scarce. Thus Chong Blood derives from Yangming Grain/Water, and Yangming Stomach Qi is root of Chong. *Classic* says: Er Yang disease originates in Heart/Spleen, hidden difficulties, women no menses. Though Heart/Spleen mentioned, emphasis is on Stomach Qi, as Heart is Mother of Stomach, Stomach is Interior of Spleen. *Classic* also says: Chest/flank fullness, difficulty eating, smelling fishy odor, clear discharge, spitting blood, cold limbs, vertigo, frequent bleeding, named Blood Dryness. Caused by major blood loss in youth or sex while drunk, Qi exhausted, Liver injured, hence menses sparse/stopped. Emphasis is on "Qi exhausted, Liver injured". *Jin Gui* details regulation methods; later scholars like Wang Jiezhai, Xue Lizhai argued thoroughly, prescribed precisely, serving as models. Ye Tianshi’s cases emphasize Eight Extraordinary Vessels, then Liver. Women use Liver as Pre-heaven; Yin nature congeals, prone to depression; depression causes Qi stagnation, then Blood stagnation. Wood disease harms Earth, hence secondary emphasis on Spleen/Stomach. Others: tonify Blood deficiency, cool Blood heat, unblock Blood stasis, soothe Qi stagnation, tonify Qi weakness. Truly a bright mirror for gynecology. (*Lin Zheng Zhi Nan*)
[Irregular Menstruation]
Menstruation once a month is like tidal trust. If monthly arrival stops after 3-5 days but continues dripping, it is either Chong/Ren Qi deficiency failing to constrain (internal injury/deficiency) or Labor/Qi-Blood injury with Pathogen invading Bao Men (external excess/abundance). Assess patient strength. ○ Women have irregular menstruation caused by disease, or disease caused by irregular menstruation. If disease causes irregularity, treat disease first; if irregularity causes disease, regulate menstruation first. (Xiao Shenzhai)
Monthly menstruation is normal. Early or late is disease. If Ying Blood deficient, failing to nourish bones/body, hair falls, face yellow, emaciated, dry/feverish. Dryness excess harms Metal (Lung), leading to cough, lung abscess, lung wasting. Strengthen Stomach/Qi, Ying Blood generates, menstruation returns. If Qi reversal causes amenorrhea, use Qi-moving/Blood-breaking formulas. (Chu Yushi)
Danxi says: Early arrival is Blood Heat; late arrival is Blood Deficiency. I argue: Early arrival can be due to Spleen Blood dryness, Spleen Qi stagnation, Liver Fire, Blood level Heat, or labor-induced Fire. Late arrival can be due to Spleen Blood deficiency, Liver Blood scarcity, or Qi/Blood weakness. Treatment: Spleen Blood dryness, Jiawei Xiaoyao San; Spleen stagnation, Jiawei Guipi Tang; Liver Fire, Jiawei Xiao Chaihu Tang; Blood Heat, Jiawei Si Wu Tang; Labor Fire, Buzhong Yiqi Tang. Late arrival: Spleen Blood deficiency, Renshen Yangying Tang; Liver Blood scarcity, Liuwei Dihuang Wan; Qi/Blood weakness, Bazhen Tang. Blood born in Spleen, hence Spleen controls Blood. Blood diseases use bitter-sweet agents to aid Yang Qi and generate Yin Blood. (Xue Lizhai)
Early arrival, though Heat, if deficiency with Heat, focus on deficiency; nourish Ying/peace Blood. Some early arrivals have no Heat; tonify Middle Qi or secure Mingmen, avoid cold/bitter herbs. Late arrival is Blood Deficiency, but some have Heat (clear/tonify), some have Blood reversal (soothe/draining). Overall, seek harmony via pulse/symptom examination. Only if Qi/Pulse excess use clearing/draining. Deficiency is common, excess rare. Key: tonify Spleen/Stomach for Blood source, nourish Kidney for Blood chamber. Knowing these two is perfect. ○ Early menstruation judged monthly generally; Blood Heat judged by whole-body signs. Do not judge occasional early flow as early due to chronic irregularity; do not judge single early flow as Heat if pulse/symptoms show no Fire. ○ Two-three times a month or bi-weekly indicates Blood/Qi chaos; treat according to cold/heat, do not generalize as early menstruation. (Zhang Jingyue)
[Obstructed Menstruation]
Women with difficult menstruation, Didang Tang governs. ○ Women with closed menstruation, hard masses persist, dry Blood inside, white discharge, Fanshi Wan governs. (*Jin Gui Yao Lue*)
Difficult menstruation means flow is not smooth. Common in women; resolving stasis, guiding Qi, harmonizing Chong/Ren suffices. Didang Tang is heavy; text lacks lower abdominal knotting, black stool, easy urination, mania, forgetfulness, chills/fever. Likely drug-heavy/disease-light, text damaged, reader beware. ○ Zang refers to inner Yin, persistent masses. Closed menstruation is old stasis. Hard mass in Yin is dried Blood. White discharge is Blood transforming to leukorrhea. Fanshi Wan suppository treats this. For damp-type discharge, suitable; likely ineffective for hard masses/dry Blood. (*Yi Zong Jin Jian*)
Amenorrhea can be due to long-term Spleen/Stomach deficiency, emaciation, Qi/Blood decline; or mental overwork, Heart Fire rising, blocking Bao Mai; or Middle Xiao (consumption), Stomach Heat/hunger, muscle wasting, fluids not rising, Sea of Blood exhausted, named Blood Dryness Amenorrhea; or due to