冷客胞门，血寒凝泣而不下者；有因躯肥，脂满痰多，占住血海地位，闭塞而不行者；有因挟寒挟热，而污血
凝滞不行者；有因食与湿痰，填塞太阴，而经闭作痛者。寒、热、虚、实，迥然不同，总不能遁乎脉之迟、
数、有力、无力间也。○血枯经闭者，指肠胃血少枯燥而言，故东垣分三焦论治。盖上焦，心主血也，劳心过
度，阴血随耗，而无以藏之于肝，由是血海枯矣。中焦，胃为气血之海，胃液不足，则谷气不
输。夫血者，水谷之精气，调和于五脏，洒陈于六腑者也。若化源既绝于中，经血自竭于下矣。下焦，大肠主
津，小肠主液，若二经津液不足，则二便尚然燥涩，何能经水营运不竭乎？明乎此，则以脉诊而分上、中、下
所因以调之，久则望其转枯为泽，经自流通矣。（《冯氏锦囊》）
血枯之与血隔，本自不同。盖隔者，阻隔也；枯者，枯竭也。阻隔者，因邪气之隔滞，血有所逆也；枯竭
者，因冲任之亏败，源断其流也。凡妇女病损至旬月半载之后，则未有不经闭者，正因阴竭，所以血枯。枯之
为义，无血而然。欲其不枯，无如养营。欲以通之，无如充之。但使雪消则春水自来，血盈则经脉自至。源泉
混混，孰能阻之？奈何今之为治者，不论有滞、无滞，多兼开导，甚则专以通利为事，岂知血滞者可通，血枯
者不可通也。血既枯矣，而复通之，则枯者愈枯，其与榨干汁者何异？为不知"枯"字之义耳。（张景岳）
血滞、血枯，不越虚、热、痰、气四证而已。血滞亦有虚热，血枯亦有虚热。故滞者不宜过于宣通，通后
又须养血益阴，使津血流通；血枯亦不可峻行补益，恐本主无力，而辛热之剂反燥精血矣。（叶以济）
妇人女子，经脉不行，有因脾胃损伤而致者，不可便认作经闭蓄血。轻用通经破血之药，须审其脾胃何如。（王节斋）
室女经闭，非先天禀弱，血气未充，即是欲男子不得，所愿不遂，思虑伤心，抑郁伤肝，以致月闭成病。
故凡寡妇、女尼，犯经闭者，与此同法。○经闭有寒热。《金匮》主于风冷积寒，东垣、洁古主于火热实结，
是皆指有余之病也。但寒、热二证，宜分内伤、外感处治。如心火不降，而三焦热结，是血衰火旺，阴不配阳，
故心气不通，热结三焦，而经闭不行，当益阴滋水，以培化源。如积冷血寒，凝结胞门，而血泣不下，是风冷
客邪，乘虚袭入，宜温经散寒，导血下行，后用养营之剂为当。（萧慎斋）
人生以血气为本，人病未有不先伤气血者。若室女童男，积想过度，多致劳损。男子则神色消散，女子则
月水先闭。盖忧愁思虑，则心伤而血竭。且心病则不能养脾，故不嗜食；脾虚则金亏，故发嗽；肾水绝则木气
不荣，而四肢干痿，故多怒。不可用青蒿、虻虫等凉血行血，宜柏子仁丸、泽兰汤，益阴血以制虚火也。（寇宗 ）
夫经水，阴血也，属冲、任二脉。其为患，有因脾胃虚，不能生血而不行者，调而补之；有因郁伤脾，血
耗而不行者，解而补之；有因胃火，血灼而不行者，清而补之；有因劳伤，心血少而不行者，静而补之；有因
怒伤肝，血涩而不行者，和而补之。有因肾水亏，不能生血而闭者，补脾肺；有因肺气虚，不能行血而闭者，
补脾胃。（薛立斋）
辨血色
凡血色有辨，固可以察虚实，亦可以察寒热。若色浓而多者，血之盛也；色淡而少者，血之衰也。此固
大概之易知也。至于紫黑之辨，有如冰炭，而人多不解，但见紫色，不分虚实，便谓热甚。不知紫赤鲜红，浓
而成片者，是皆新血妄行，多由热也；若紫而兼黑，或散或薄，沉黑色败者，多以真气内损，必属虚寒。或如
屋漏水，或如腐败之宿血，是皆紫黑之变象也。此肝脾大损，阳气大陷，当用甘温，如理阴煎、理中汤、归脾
汤、补中汤之类，则陷者举，脱者固，元气渐复，病无不愈。若尽以紫色作热证，则无不随药而毙矣。（张景岳）
天癸过期
妇人天癸过期，而经犹行者，其故有三∶一主于有余，一主于邪伤，一主于败血。败血即属崩漏，当以禀
赋强弱参之。（萧慎齐）
妇人年过五十而经行不止者，作败血论。（李时珍）
妇人四旬外，经期将断之年，多有渐见阻隔，经期不至者，此际最宜防察。若果气血和平，素无他疾，此
固渐止而然，无足
虑也。若素多忧郁不调之患，而见此过期阻隔，便有崩决之兆。若隔之浅者，其崩尚轻；隔之久者，其崩必甚。
当预服药调之，否则患滋大也。（张景岳）
脉候
凡血气壮盛，经络遏闭，其脉滑实。外风冷伤，经络凝涩，其脉浮涩。形体憔悴，经络涸竭，其脉虚弱。（杨仁斋）
选案
有妇人生女，年十五来诊。言十四时，经水自下，今经反断，何也？师曰∶必夫人年十四时，亦经水下，
所以断。此为避年，后当自下。此真气怯，禀赋素弱而然，宜固真气，使水升火降，则五脏调和，经脉自通。（王叔和）
一妇病疟，食少，经期不行，诊两手无脉，时值寒月，拟作虚寒治之，与四物汤加附子、吴萸。复诊，见
其起居如常。惊曰∶误矣！经不行者，非无血也，乃痰碍而不行；无脉者，非血衰也，乃积痰生热，结伏而脉
不见尔。易作实热治之，用三花神佑丸，脉出经通而愈。（朱丹溪）
一妇，经行必先泻二、三日，诊其脉，皆濡弱，此脾虚也。脾主血属湿。经水将动，脾血先已流注血海，
然后下流为经。脾虚不能营运其湿，以参苓白术散服之。月余，经行不泻矣。（汪石山）
杨季登女，经闭年余，发热少食，肌削多汗，而成劳怯。医见汗多，误为虚也，投以参、术，其血愈锢。
诊时，见汗出如蒸笼气水。谓曰∶此证可疗处，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，而汗自止，非
补药所能效也。于是以龙荟丸，日进三次，月余，经血略至，汗热稍轻，姑减前丸，只日进一次。又一月，经
血大行，淋漓五日，而诸证全瘳矣。（喻嘉言）
[Menses (Continued)]
When cold pathogens invade the uterus, causing blood to congeal and stagnate due to cold, resulting in amenorrhea; or when obesity leads to excessive fat and phlegm-dampness occupying the position of the Blood Sea, blocking the channels and preventing menstruation; or when accompanied by cold or heat pathogens, causing turbid blood to stagnate and not flow; or when dietary retention and damp-phlegm fill and obstruct the Taiyin Spleen channel, leading to amenorrhea with pain. The patterns of Cold, Heat, Deficiency, and Excess are distinctly different, yet they can always be distinguished through the pulse characteristics of Slow, Rapid, Forceful, or Weak. ○ Amenorrhea due to Blood Exhaustion refers to a state where the intestines and stomach have little blood and are dry. Therefore, Li Dongyuan divided the treatment according to the Upper, Middle, and Lower Jiao. In the Upper Jiao, the Heart governs the blood. Overwork of the mind consumes Yin blood, which cannot then be stored in the Liver, leading to the exhaustion of the Blood Sea. In the Middle Jiao, the Stomach is the sea of Qi and Blood. If Stomach fluids are insufficient, the essence of grain and water cannot be transported. Blood is the refined essence of food and drink, harmonized within the Five Zang organs and distributed throughout the Six Fu organs. If the source of transformation in the Middle Jiao is exhausted, the menstrual blood at the Lower Jiao will naturally deplete. In the Lower Jiao, the Large Intestine governs Jin-Ye (body fluids), and the Small Intestine governs Ye (thick fluids). If the fluids of these two meridians are insufficient, bowel movements and urination will be dry and difficult; how can menstrual flow remain unending? Understanding this, one can differentiate the causes in the Upper, Middle, and Lower Jiao via pulse diagnosis and treat accordingly. Over time, one may hope for the transition from dryness to moisture, and menstruation will naturally flow smoothly. (From *Feng Shi Jin Nang*)
Blood Exhaustion and Blood Obstruction are fundamentally different. "Obstruction" implies blockage; "Exhaustion" implies depletion. Obstruction is caused by pathogenic factors blocking and stagnating, causing blood to rebel; Exhaustion is caused by the deficiency and failure of the Chong and Ren vessels, cutting off the source of the flow. For women who have suffered illness for half a month to half a year, amenorrhea invariably occurs because Yin essence is exhausted, leading to blood depletion. The meaning of "exhaustion" is that there is no blood. To prevent exhaustion, nothing is better than nourishing Ying (Nutritive) Qi. To promote flow, nothing is better than replenishment. Just as melting snow brings spring water naturally, when blood is abundant, the menses will arrive on their own. When the source flows continuously, who can stop it? Yet, today's practitioners, regardless of whether there is stagnation or not, often use opening and guiding methods, even specializing in purgatives and diuretics. They do not know that while stagnant blood can be moved, exhausted blood cannot be forced. If blood is already exhausted and one forces its movement, the exhaustion becomes worse; what is the difference from squeezing out all the juice? This stems from a lack of understanding of the meaning of "exhaustion." (Zhang Jingyue)
Blood Stagnation and Blood Exhaustion fall into four categories: Deficiency, Heat, Phlegm, and Qi. Blood Stagnation can involve Deficient Heat, and Blood Exhaustion can also involve Deficient Heat. Therefore, for stagnation, one should not overuse promoting and moving methods; after moving it, one must nourish Blood and benefit Yin to ensure the free flow of Jin-Ye and Blood. For Blood Exhaustion, one must not use harsh tonification, lest the weak root cannot withstand it, and acrid-warm agents might instead dry up Essence and Blood. (Ye Yiji)
In women, amenorrhea caused by Spleen-Stomach damage should not be immediately diagnosed as amenorrhea with blood stasis. One must not lightly use drugs that promote menstruation and break blood stasis; one must carefully examine the condition of the Spleen and Stomach. (Wang Jiezhai)
Amenorrhea in unmarried girls is either due to weak congenital endowment and insufficient Qi and Blood, or due to unfulfilled desires to marry, leading to excessive thinking that damages the Heart and depression that damages the Liver, resulting in closed menses. Thus, widows and nuns suffering from amenorrhea should be treated with the same methods. ○ Amenorrhea can present as Cold or Heat. *Jin Gui Yao Lue* attributes it to wind-cold accumulation, while Li Dongyue and Jiegu attribute it to fire-heat excess and knotting; both refer to Excess patterns. However, Cold and Heat patterns should be differentiated based on internal injury versus external contraction. For example, if Heart Fire does not descend and the Three Jiao is heat-knotted, this indicates Blood deficiency with Fire hyperactivity, where Yin fails to match Yang. Consequently, Heart Qi is blocked, heat knots the Three Jiao, and menstruation stops. Treatment should benefit Yin and nourish Water to cultivate the source of transformation. If accumulated cold and cold blood congeal in the uterus, causing blood to stagnate and not flow, this is due to wind-cold pathogens invading due to deficiency. Treatment should warm the meridians and dissipate cold to guide blood downward, followed by nourishing Ying formulas. (Xiao Shenzhai)
Human life is rooted in Qi and Blood; illness invariably injures Qi and Blood first. In young men and women, excessive rumination often leads to consumptive disease. Men show dissipation of spirit and complexion, while women experience early cessation of menses. Worry and anxiety damage the Heart and exhaust blood. Since Heart disease fails to nourish the Spleen, appetite decreases; Spleen deficiency leads to Lung Metal deficiency (Earth failing to generate Metal), causing cough; Kidney Water exhaustion means Liver Wood lacks nourishment, leading to dry and flaccid limbs and irritability. Qinghao (Artemisiae Annuae Herba) and Mengchong (Ophryodactylus) should not be used to cool blood and move blood; instead, Baizi Ren Wan (Biota Seed Pill) or Zelan Tang (Lycopus Decoction) should be used to nourish Yin Blood and control deficient fire. (Kou Zongshi)
Menstrual blood is Yin Blood, belonging to the Chong and Ren vessels. Causes of disorder include: Spleen-Stomach deficiency failing to generate blood, requiring regulation and tonification; Depression damaging the Spleen and consuming blood, requiring resolution of depression and tonification; Stomach Fire scorching blood, requiring clearing and tonification; Labor injury reducing Heart Blood, requiring quietude and tonification; Anger damaging the Liver and causing blood stagnation, requiring harmonizing and tonification. Kidney Water deficiency failing to generate blood requires tonifying Spleen and Lung; Lung Qi deficiency failing to move blood requires tonifying Spleen and Stomach. (Xue Lizhai)
Differentiation of Blood Color
The color of menstrual blood can distinguish Deficiency/Excess and Cold/Heat. Thick and abundant blood indicates Blood Excess; pale and scant blood indicates Blood Deficiency. This is generally easy to understand. However, the distinction between purple and black colors is like ice and charcoal, yet many do not understand it. Seeing purple color, people indiscriminately diagnose severe Heat. They do not realize that bright red-purple, thick and clotted, indicates new blood flowing recklessly, usually due to Heat. If the color is purple mixed with black, scattered or thin, or dark and decayed, it is due to internal damage of True Qi and belongs to Deficient Cold. Colors resembling roof leak water or rotten old blood are variations of purple-black. These indicate severe damage to the Liver and Spleen and collapse of Yang Qi. Sweet-Warm formulas such as Li Yin Jian (Replenish Yin Decoction), Li Zhong Tang (Regulate the Middle Decoction), Gui Pi Tang (Restore the Spleen Decoction), or Bu Zhong Yi Qi Tang (Tonify the Middle and Augment Qi Decoction) should be used to raise collapsed Qi and secure lost blood, allowing Yuan Qi to recover and the disease to heal. If all purple colors are treated as Heat patterns, death will inevitably follow the medication. (Zhang Jingyue)
Post-Menopausal Bleeding
For women past the age of Tian Gui (menopause) whose menstruation continues, there are three causes: Excess of healthy Qi, injury by pathogens, or敗血 (decayed blood). Decayed blood falls under the category of metrorrhagia and metrostaxis (bing lou); one must consider the strength of the patient's constitution. (Xiao Shenqi)
Women over fifty years old with continuous menstruation should be treated as having decayed blood. (Li Shizhen)
Women in their forties, approaching the end of their menstrual cycle, often experience gradual obstruction and cessation of periods. This period requires careful observation. If Qi and Blood are peaceful and the patient has no other chronic illnesses, this is simply a natural gradual cessation and need not be worried about. However, if the patient has a history of depression and disharmony, this post-menopausal obstruction signals a potential risk of sudden heavy bleeding (bing jue). If the obstruction is shallow, the subsequent bleeding will be mild; if long-standing, the bleeding will be severe. Medication should be administered preemptively to regulate the condition; otherwise, the affliction will worsen. (Zhang Jingyue)
Pulse Signs
When Qi and Blood are robust but channels are blocked, the pulse is Slippery and Excess. When external wind-cold injures the body and channels become congealed and stiff, the pulse is Floating and Choppy. When the physique is emaciated and channels are exhausted, the pulse is Weak and Deficient. (Yang Renzhai)
Selected Cases
A woman who had given birth to a daughter came for consultation at age fifteen. She stated her menses began at fourteen but had now stopped. The physician said: Your mother likely also had her menses begin at fourteen and then stopped. This is called "Bi Nian" (Avoidance Year); menstruation will resume spontaneously. This is due to weak True Qi and congenital deficiency. Treatment should consolidate True Qi, ensuring Water rises and Fire descends, harmonizing the Five Zang organs so the channels open naturally. (Wang Shuhe)
A woman suffering from malaria had poor appetite and amenorrhea. Her pulses were imperceptible in both hands. It was winter, so she was initially treated for Deficient Cold with Si Wu Tang (Four Substances Decoction) plus Fuzi (Aconiti Lateralis Radix Praeparata) and Wuyu (Evodiae Fructus). On follow-up, she appeared normal. The physician exclaimed: I was mistaken! Amenorrhea is not due to lack of blood, but obstruction by Phlegm. Absent pulses are not due to blood deficiency, but due to accumulated phlegm generating heat, knotting internally and hiding the pulse. Changing the diagnosis to Excess Heat, he prescribed San Hua Shen You Wan (Three Flowers Divine Protection Pill). The pulse returned, menstruation resumed, and she recovered. (Zhu Danxi)
A woman experienced diarrhea for two to three days prior to every menstrual period. Her pulse was Soft and Weak, indicating Spleen Deficiency. The Spleen governs Blood and Dampness. Before menstruation begins, Spleen Blood flows into the Blood Sea before descending as menstrual flow. Due to Spleen Deficiency failing to transport Dampness, she was given Shen Ling Bai Zhu San (Ginseng, Poria, and Atractylodes Macrocephala Powder). After more than a month, her menstruation occurred without diarrhea. (Wang Shishan)
Yang Jideng’s daughter had been amenorrheic for over a year, presenting with fever, poor appetite, muscle wasting, and sweating, developing into a consumptive disease. Physicians saw the profuse sweating and misdiagnosed it as Deficiency, administering Renshen (Ginseng Radix) and Baizhu (Atractylodis Macrocephalae Rhizoma), which further bound the blood. Upon examination, the sweat resembled steam from a steamer. The physician said: The key to treating this case lies in the presence of sweat. Because menstrual blood is internally closed, the only exit is through the skin pores, as sweat is also blood. Without sweat, the skin would dry out and death would ensue. Bitter-cold herbs should be used to draw the blood inward and connect to the Chong vessel, thereby reducing fever, restoring menstruation, and stopping sweat. Tonics would be ineffective. Long Hui Wan (Dragon Ash Pill) was administered three times daily. After a month, slight menstruation occurred, and fever/sweating lessened. The dosage was reduced to once every other day. Another month later, heavy menstruation lasted five days, and all symptoms resolved. (Yu Jiayan)