白术 芎藭 蜀椒(去汗)三分 牡蛎
右四味,杵为散,酒服一钱匕,日三服,夜一服。但苦痛加芍药;心下毒痛,倍加芎
藭;心烦吐痛,不能食饮,加细辛一两,半夏大者二十枚,服之后,更以醋浆水服之
。若呕,以醋浆水服之复不解者,小麦汁服之。已后渴者,大麦粥服之,病虽愈,服
之勿置。
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妇人伤胎,怀身腹满,不得小便,从腰以下重,如有水气状,怀身七月,太阴当养不
养,此心气实,当刺泻劳宫及关元,小便微利则愈。
【按】
文义未详,此穴刺之落胎,必是错简,不释。
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问曰:新产妇人有三病:一者病痉,二者病郁冒,三者大便难,何谓也?师曰:新产
血虚,多汗出,喜中风,故令病痉。亡血复汗,寒多,故令郁冒。亡津液,胃燥,故
大便难。
【注】
新产之妇,畏其无汗,若无汗则荣卫不和,而有发热无汗,似乎伤寒表病者,但舌无
白苔可辨也,故喜其有汗,而又恐汗出过多,表阳不固,风邪易入,而为项强腰背反
张之痉病也。新产之妇,畏血不行,若不行则血瘀于里,而有发热腹痛,似乎伤寒里
病者,但以舌无黄胎可辨也,故喜其血下,而又恐血下过多,阴亡失守,虚阳上厥,
而为昏冒不省,合目汗出之血晕也。新产虽喜其出汗,喜其血行,又恐不免过伤阴液
,致令胃干肠燥,而有潮热谵语,大便□难,似乎阳明胃家实者。故仲景于产后首出
三病,不只为防未然之病,而更为辨已然之疑也。昏冒而曰郁冒者,谓阴阳虚郁,不
相交通而致冒也。
【集注】
尤怡曰:痉,筋病也,血虚汗出,筋脉失养,风入而益其劲也。郁冒,神病也,亡阴
血虚,阳气遂厥,而阴复郁之,则头眩而目瞀。大便难者,液病也,胃藏津液,渗灌
诸阳,亡津液胃燥,则大肠失其润而便难也。三者不同,其为亡血伤津则一也。
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产妇郁冒,其脉微弱,不能食,大便反坚,但头汗出。所以然者,血虚而厥,厥而必
冒,冒家欲解,必大汗出;以血虚下厥,孤阳上出,故头汗出。所以产妇喜汗出者,
亡阴血虚,阳气独盛,故当汗出,阴阳乃复,大便坚,呕不能食,小柴胡汤主之。病
解能食,七、八日更发热者,此为胃实,大承气汤主之。
【注】
此承上条互详其义,以明其治也。产妇昏冒,脉微弱者,是气血俱虚应得之诊也。不
能食者,是胃气未和应得之候也。大便反坚者,是肠胃枯干应得之病也。究之郁冒所
以然者,由血虚则阴虚,阴虚则阳气上厥而必冒也。冒家欲解,必大汗出者,是阳气
郁得以外泄而解也,故产妇喜汗出也。由此推之,血瘀致冒,解必当血下,是阴气郁
得以内输而解也。最忌者,但头汗出,则为阴亡下厥,孤阳上出也。大便坚,呕不能
食,用小柴胡汤,必其人舌有胎身无汗,形气不衰者始可,故病得解,自能食也。若
有汗当减柴胡,无热当减黄芩,呕则当倍姜、半,虚则当倍人参,又在临证之变通也
。大便坚,七、八日更发热,用大承气汤,亦必其人形气俱实,胃强能食者始可也。
若气弱液干,因虚致燥,难堪攻下者,则又当内用元明粉以软坚燥,外用诸导法以润
广肠,缓缓图之也。
【集注】
尤怡曰:郁冒虽有客邪,而其本则为里虚,故其脉微弱也。呕不能食,大便反坚,但
头汗出,津液上行不下逮之像。所以然者,亡阴血虚,孤阳上厥,而津液从之也。厥
者必冒,冒家欲解,必大汗出者,阴阳乍离,故厥而冒,及阴阳复通,汗乃大出而解
也。产妇新虚,不宜多汗,而此反喜汗出者,血去阴虚,阳受邪气而独盛,汗出则邪
去,阳弱而后与阴相合,所谓损阳而就阴是也。
Baizhu (Atractylodis Macrocephalae Rhizoma), Xiongqiong (Ligusticum Chuanxiong Rhizoma), Shujiao (Zanthoxyli Pericarpium, removed of sweat) each 3 fen, Musli (Ostreae Concha).
The above four ingredients are pounded into a powder. Take one qianbi (a small measure) with wine, three times a day and once at night. If pain is severe, add Shaoyao (Paeoniae Radix Alba); if there is severe pain in the epigastrium, double the dosage of Xiongqiong; if there is irritability, vomiting, pain, and inability to eat or drink, add Yixin (Asari Radix et Rhizoma) 1 liang and Banxia (Pinelliae Rhizoma) twenty large pieces. After taking this, take it again with Cujiangshui (vinegar water). If vomiting occurs, take it with vinegar water; if it does not resolve, take it with Xiaomai Zhi (wheat juice). If thirst develops subsequently, take Damai Zhou (barley porridge). Even if the disease has healed, continue taking it and do not stop.
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When a woman suffers from damaged fetus, she experiences abdominal fullness during pregnancy, inability to urinate, and heaviness from the waist down, resembling edema. At seven months of pregnancy, when the Taiyin meridian should nourish the fetus but fails to do so, this is due to excess Heart Qi. It is indicated to puncture Laogong (PC 8) and Guanyuan (CV 4) using the reducing method. The condition will heal when urination becomes slightly free.
[Commentary]
The meaning of this text is unclear. Puncturing these acupoints may cause abortion; this must be a textual error in the bamboo slips, so it is not explained.
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Question: What are the three diseases affecting women shortly after childbirth? One is Jing illness (spasm), the second is Yumao (depression and vertigo), and the third is difficult defecation. What does this mean?
Master said: Postpartum blood deficiency, excessive sweating, and susceptibility to wind pathogen lead to Jing illness (spasm). Loss of blood combined with sweating leads to excess cold, causing Yumao (depression and vertigo). Depletion of body fluids and dryness of the Stomach lead to difficult defecation.
[Annotation]
For women who have just given birth, lack of sweating is feared because it indicates disharmony between Ying (Nutrient) and Wei (Defensive) qi, presenting with fever and no sweating, resembling Exterior Syndrome of Cold Damage. However, the absence of white coating on the tongue distinguishes it. Therefore, sweating is desired, but excessive sweating is feared as it fails to secure Exterior Yang, allowing Wind pathogen to invade easily, leading to neck stiffness, opisthotonos, and Jing illness (spasm). For postpartum women, stagnation of blood is feared because blood stasis in the interior presents with fever and abdominal pain, resembling Interior Syndrome of Cold Damage. However, the absence of yellow coating on the tongue distinguishes it. Therefore, lochia discharge is desired, but excessive loss is feared as it leads to collapse of Yin blood and failure of Zheng Qi (Upright Qi), causing deficient Yang to rebel upward, leading to coma, unconsciousness, and Xueyun (blood syncope) with closed eyes and sweating. Although postpartum sweating and blood flow are desirable, excessive damage to Yin fluids is feared, leading to dry stomach and intestines, tidal fever, delirious speech, and difficult defecation, resembling Yangming Stomach Excess Syndrome. Thus, Zhang Zhongjing first mentions these three diseases postpartum not only to prevent potential illnesses but also to differentiate suspected existing conditions. Coma termed Yumao refers to depression caused by deficiency and stagnation of Yin and Yang, preventing their communication.
[Collected Notes]
You Yi stated: Jing illness (spasm) is a disorder of the sinews; blood deficiency and sweating cause the sinews and vessels to lose nourishment, and Wind invasion exacerbates stiffness. Yumao (depression and vertigo) is a disorder of the Shen (Spirit); Yin-blood deficiency causes Yang to rebel upward, while Yin stagnates above, leading to dizziness and blurred vision. Difficult defecation is a disorder of fluids; the Stomach stores body fluids and moistens the Yang meridians. Depletion of fluids causes Stomach dryness, leading to lack of lubrication in the Large Intestine and difficult defecation. Although these three diseases differ, they all stem from loss of blood and injury to fluids.
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In postpartum Yumao (depression and vertigo), the pulse is faint and weak, the patient cannot eat, the stool is hard, and only the head sweats. This is because blood deficiency leads to Jue (rebellious Qi), and Jue inevitably leads to Mao (vertigo/coma). For Mao to resolve, profuse sweating must occur. Due to blood deficiency and lower Jue, isolated Yang floats upward, causing only the head to sweat. Therefore, postpartum women benefit from sweating because Yin-blood depletion leaves Yang in excess. Sweating allows Yin and Yang to restore balance. For hard stool, vomiting, and inability to eat, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the primary treatment. If the disease resolves and appetite returns, but fever recurs after seven or eight days, this indicates Stomach Excess, treated with Da Cheng Qi Tang (Major Order the Qi Decoction).
[Annotation]
This paragraph elaborates on the previous one to clarify the treatment. Faint and weak pulse in postpartum coma indicates dual deficiency of Qi and Blood. Inability to eat indicates unharmonized Stomach Qi. Hard stool indicates dryness of the intestines. The cause of Yumao is that blood deficiency leads to Yin deficiency, which causes Yang to rebel upward, resulting in coma. Profuse sweating resolves Yao because it allows stagnant Yang to dissipate outward, hence postpartum women benefit from sweating. By inference, if coma is caused by blood stasis, resolution requires lochia discharge, allowing stagnant Yin to circulate inward. The most dangerous sign is sweating only on the head, indicating Yin collapse and lower Jue with floating isolated Yang. For hard stool, vomiting, and inability to eat, Xiao Chai Hu Tang is used, but only if the patient has tongue coating, no body sweating, and robust constitution. Upon resolution, appetite returns. If sweating is present, reduce Chai Hu (Bupleuri Radix); if no heat, reduce Huang Qin (Scutellariae Radix); for vomiting, increase Jiang (Zingiberis Rhizoma Recens) and Banxia (Pinelliae Rhizoma); for deficiency, increase Renshen (Ginseng Radix et Rhizoma). These require clinical flexibility. For hard stool and recurrent fever after seven or eight days, Da Cheng Qi Tang is used, but only if the patient has robust Qi and form and strong Stomach function. If Qi is weak and fluids dry, causing dryness due to deficiency, which cannot withstand purgation, then Yuan Ming Fen (Natrii Sulfas) should be taken internally to soften hardness, and external enemas/lubricants should be used to moisten the rectum, proceeding slowly.
[Collected Notes]
You Yi stated: Although Yumao involves external pathogens, its root is internal deficiency, hence the faint pulse. Vomiting, inability to eat, hard stool, and head-only sweating indicate fluids rising but failing to reach the lower part. This is because Yin-blood depletion causes isolated Yang to rebel upward, carrying fluids with it. Jue leads to Mao; resolution requires profuse sweating as Yin and Yang temporarily separate, causing Jue and Mao, and upon reconnection, sweating occurs and the disease resolves. Postpartum women are newly deficient and should not sweat excessively. Here, sweating is beneficial because blood loss causes Yin deficiency, leaving Yang dominant due to pathogenic factors. Sweating expels the pathogen, weakening Yang so it can combine with Yin, described as "diminishing Yang to follow Yin."