（一名胎前伤寒）
【因】妇人怀孕。寒邪外束。营气不能灌注。故发热恶寒。身疼腰痛。谓之伤寒。头痛恶风。
身热心烦。谓之伤风。邪在半表半里。则往来寒热。
【证】邪在表身热。恶寒无汗。头疼身痛。在里则腑热壅闭。大便不通。若寒在半表。热在半里。
则往来寒热。烦渴不解。若寒侵于表。风伤营气。则身疼头痛。发热恶寒。妊娠气血不足。不能
营卫于外。而风邪乘虚袭入经中。则身热自汗。倦怠恶风。妊娠营血不足。寒即袭入经中。则身疼
无汗。发热恶寒。
【脉】妊娠人迎紧盛。伤于寒。营气虚者。脉必浮弱。气口浮缓。伤于风。卫气虚者。脉必浮软。
营卫两虚。邪不解散。脉必细微。
【治】疏邪解表。以治其标。扶元托散。以培其本。营虚者。养血为先。卫虚者。补气为亟。
营卫两虚。温补并施。邪在表者。其证恶寒身热。头痛无汗。脉浮者。主以香苏饮。（生香附、
紫苏、陈皮、甘草、生姜、葱头。）病在里者。其证里热壅闭。大便不通。脉洪数者。治以三黄解
毒汤。（黄连黄芩、黄柏、焦栀子、大黄。）在半表半里者。寒热往来。烦渴不解。脉弦数者。
主以黄龙汤（柴胡、黄芩、人参、甘草、生姜、大枣。）营虚者。寒多热少。不烦不渴。脉弦浮涩者。
主以当归桂枝汤。（当归、桂枝、白芍、甘草、煨姜、大枣。）卫虚者。寒邪留恋经中。则寒热
不解。脉浮软者。主以黄 建中汤。（炙黄 、桂枝、白芍、炙甘草、生姜、大枣。）伤寒寒已外
解。脾气虚馁。热乘虚陷。胎动不安。主以安胎散。（生
白术、黄芩、炒白芍等分为散。以生姜二片、大枣三枚。煎浓汁调服三钱）兼有潮热者。主以安胎阿胶散。
（炒阿胶三两、党参一两五钱、白术一两五钱、茯苓一两五钱、桑寄生三两。炒制为散。米饮调下三
钱。）妊娠伤寒。侵表伤营。头痛发热。恶寒身痛。胎孕不安。脉浮紧涩者。主以羌活散。（羌活、
生白术、防风、炒白芍、黄芩各一两五钱、当归三两、白芷川芎各一两、甘草六钱、制为散、
水煎五钱、去渣温服。）妊娠伤风。风邪乘虚袭入经中。身热自汗。倦怠恶风。胎孕不安。脉浮缓者。
主以黄 解肌散。（人参一两五钱、黄 三两炙、当归三两、炒白芍一两五钱、川芎一两、炙甘草
五钱、制为散、紫苏汤下三钱。）妊娠营血不足。寒袭经中。身疼无汗。发热恶寒。胀浮弱者。
主以桂枝芍药汤。（桂枝芍药各钱半、当归三钱、生姜两片、葱头三枚。）妊娠伤寒表解后。里气不和。
腹中痛。下利胎动。脉沉者。主以芍药汤（炒白芍三钱、炒白术、茯苓各钱半、炙甘草八分。）妊
娠伤寒表解后。腹中不和。协热下利。胎不安。脉数者。主以加味黄芩汤。（炒白芍、炒白术、黄芩、
茯苓各钱半、炒阿胶二钱、炙甘草五分。）妊娠伤寒。火郁不解。营阴受伤。而夹湿热。发斑紫黑。
胎因不安。脉数弦大者。主以栀子大青汤。（鲜生地五钱、升麻五分、焦栀子三钱。鲜大青四钱、
黄芩二钱、葱头三枚。）妊娠伤寒。热郁阳明。热极而发紫黑斑。脉洪数者。若不急治。胎殒在即。
主以青黛石膏汤（真青黛钱半、鲜生地二两捣汁。生石膏八钱、升麻六分、黄芩二钱、焦栀子三钱、
葱头三枚。）妊娠伤寒后。余热阻膈。血气暗耗。潮热不解。胎孕不安。脉数濡弦者。主以黄龙四物汤。
（鲜生地五钱、党参、黄芩白芍各钱半、柴胡五分、当归三钱、川芎、甘草各八分。）妊娠伤寒。
发汗后。余热内陷。卫气无所止息。漏汗不止。胎孕不安。脉浮数者。主以加减当归六黄汤（大生地五钱、
清炙 皮三钱、炒白芍、炙甘草、黄芩各钱半。白芷盐水
炒黑二钱、当归、炒阿胶各三钱、浮小麦三钱）妊娠伤寒汗下后、津液暴亡。虚烦不眠。胎孕不安。脉濡数者。
主以加味竹叶汤。（淡竹叶三钱。北沙参三钱、鲜生地五钱、麦冬、炒阿胶各三钱。炙甘草五分。）
妊娠伤寒。热极伤营。血室受病。恐损坏其胎。徐洄溪以白药脂八两研末。以鸡子清调涂油纸上。
贴脐下胎存处。干则以水润之。解毒润燥以护胎元。叶天士亦谓胎前病。以护胎为要。恐邪来害娠也。
如热极。用井底泥。蓝布浸透。覆盖脐腹上。此亦保护胎元之法。然亦须看其邪之可解而用之。
如用血分滋腻之药不效。又当审察应下则下。惟中病则止。不可固执成法。仍须步步保护胎元。恐正损邪陷也。
【秀按】妊娠伤寒治法。前论已备。不复再赘。凡邪热壅盛之症。不可固执成例。以滋腻安胎之药投之。以
助长邪热。反损胎元。即经云有故无殒。亦无殒也。大积大聚。不可犯也。损其大半而止。过则杀也。亦为治
妊娠伤寒之要诀。吴又可云。孕妇伤寒时疫。设应用三承气汤。须随证施治。慎毋惑于参术阿胶之说。病家见
用承气。先自惊疑。或更左右嘈杂。必致医家掣肘。为子母大不祥。若应下之证。反用补剂。邪火壅郁。热毒
愈炽。胎更不安。耗气搏血。胞胎何赖。是以古人有悬钟之喻。梁腐而钟未有不落者。惟用承气逐去其邪。火
毒消散。炎 顿为清凉。气回而胎自固。当此证候。反见大黄为安胎之圣药。历治历当。子母俱安。若腹痛如
锥。腰痛如折。此胎将堕欲堕之候。服药亦无及矣。虽投承气。但可愈疾而全母。昧者以为胎堕。必反咎于医
也。或诘余曰。孕妇而投承气。设邪未逐。先损其胎。当如之何。余曰。结粪淤热。肠胃间事也。胎附于脊。
肠胃之外。子宫内事也。药先到胃。瘀热才通。胎气便得舒养。是以兴利除害于顷刻之间。何虑之有。但投药
之际。病衰七八。余邪自愈。慎弗过剂耳。即经所言损其大半而止也。
【廉勘】周澹然云。妊娠之妇。一受温邪。胎为热伤。势在必下。胎下母亦难全。处此危急之际。不妨向病
家帮助原委。急当速彻其热。以希侥幸。往往如此施治。不但胎不下坠。而反安然无事。岐伯云。有故无殒。
亦无殒也。诚哉斯言。吴又可又有悬钟之喻。于理更切。要之此时下胎亦坠。不下胎亦坠。然下之胎坠。母犹
可救十中二三。不下则母无生理。胎亦焉能独存。更有妊妇一病温证。舌即干红。苔或黑或焦燥。此属邪
热过重。非大剂重剂。不能破格救人。攻下药中。惟减去芒硝。恐损胎也。亦有胎死腹中。舌见青黑。又非
芒硝。死胎不能下也。尤宜向病家声明再用。不致受人谤毁。
【荣斋按】《客尘医话》作者计寿乔诊疗妊娠伤寒，除辨证外，必察舌苔。他说∶“妊娠伤寒及温热症，
最难措手，须辨舌苔，张诞先《舌鉴》六条，实为名论，治宜宗之∶“（一）孕妇初伤于寒，见舌赤，舌上
白滑，即当微汗之，以解其表，如面舌俱白，发热，多饮冷水，阳极变阴所致，当用温中之药。若见厥冷烦
躁，误与凉剂，则厥逆吐利而死。（二）面赤舌黄，五六日，里症见，当微利之，庶免热邪伤胎之患；若面
舌俱黄，此失于发汗，湿热入里所致，当用清热利水药。（三）面舌俱黑，水火相刑，不必问其月数，子母
俱死。面赤舌微黑者，还当保胎。如见灰色，乃邪入子宫，其胎必不能固。若面赤者，根本未伤，当急下
以救其母。（四）妊娠伤寒温热，见面舌俱赤，宜随症汗下，子母无虞。而色皎白而舌赤者，母气素虚，
当略用温散法。若面黑舌赤，亦非吉兆；若在临月，则子生而母当殒。（五）见面赤舌紫，其人必嗜饮，
乃酒毒内传所致；如淡紫带青，为阴症夹食，难治也，即用枳实理中，四逆辈，亦难为力。若面赤舌青，母
虽无妨，子殒腹内，急用芎归汤合平胃散加朴硝下之；以救其母。（六）面黑而舌干卷短，或黄黑刺裂，
乃里症至急，不下则热邪伤胎，下之危在顷刻；如无循衣撮空直视等症，十中可换回一二。”至于妊娠伤风，
首宜固胎顺气，虽见脉紧无汗，不可用麻黄、青龙及一切解表猛剂；以风药性升，皆犯胎气也。郑虚谷曰∶
“妊娠伤风，无论时月及月分多少，俱宜严氏紫苏饮加葱白为至稳。”计氏为清代秀水县人，陆定圃《冷卢医话》
称他“深谙医理，尤精妇科，诊胎产
症二十余年，凡大险大危者，十中挽回七八。”则知他是一个妇科专家，经验一定可靠的。
(Also known as Taiqian Shanghan / Pre-pregnancy Cold Damage)
[Etiology]
When a woman is pregnant, cold pathogenic factors bind the exterior. Ying Qi (Nutritive Qi) cannot circulate and irrigate properly, resulting in fever, aversion to cold, body pain, and lower back pain; this is termed Shanghan (Cold Damage). If headache, aversion to wind, body heat, and irritability occur, it is termed Shafeng (Wind Injury). If the pathogen resides at the half-exterior half-interior level, alternating chills and fever occur.
[Syndromes]
When the pathogen is at the exterior, symptoms include body heat, aversion to cold, absence of sweating, headache, and body pain. When the pathogen is at the interior, there is hyperthermia and obstruction of the fu organs with constipation. If cold is at the half-exterior and heat is at the half-interior, alternating chills and fever with persistent irritability and thirst occur. If cold invades the exterior and wind damages the Ying Qi, body pain, headache, fever, and aversion to cold manifest. Due to insufficient Qi and Blood during pregnancy, the defensive and nutritive functions fail to protect the exterior, allowing wind pathogens to invade the meridians vacuously, causing body heat, spontaneous sweating, fatigue, and aversion to wind. If Ying Blood is insufficient during pregnancy, cold pathogens invade the meridians, causing body pain, absence of sweating, fever, and aversion to cold.
[Pulse Diagnosis]
In pregnant women, a tight and full Renying pulse indicates cold injury. A floating and weak pulse indicates deficiency of Ying Qi. A floating and moderate Qi Kou pulse indicates wind injury. A floating and soft pulse indicates deficiency of Wei Qi. If both Ying and Wei Qi are deficient and the pathogen remains unresolved, the pulse will be fine and minute.
[Treatment]
Dispel pathogens and release the exterior to treat the branch; support Yuan Qi and expel pathogens to nourish the root. For Ying deficiency, nourishing Blood is prioritized; for Wei deficiency, tonifying Qi is urgent. For dual deficiency of Ying and Wei, warm tonification is applied simultaneously.
For pathogen at the exterior, presenting with aversion to cold, body heat, headache, absence of sweating, and a floating pulse, the main formula is Xiangsu Yin (Fragrant Cinnamon Twig Decoction) [Sheng Xiangfu, Zi Su, Chen Pi, Gan Cao, Sheng Jiang, Cong Tou].
For disease at the interior, presenting with interior heat obstruction, constipation, and a surging rapid pulse, the treatment is Sanhuang Jiedu Tang (Three Yellows Detoxification Decoction) [Huang Lian, Huang Qin, Huang Bai, Jiao Zhi Zi, Da Huang].
For the half-exterior half-interior stage, presenting with alternating chills and fever, persistent irritability and thirst, and a string-taut rapid pulse, the main formula is Huanglong Tang (Yellow Dragon Decoction) [Chai Hu, Huang Qin, Ren Shen, Gan Cao, Sheng Jiang, Da Zao].
For Ying deficiency, presenting with more chills than fever, no irritability or thirst, and a string-taut, floating, and choppy pulse, the main formula is Danggui Guizhi Tang (Angelica Cinnamon Twig Decoction) [Dang Gui, Gui Zhi, Bai Shao, Gan Cao, Wei Jiang, Da Zao].
For Wei deficiency, where cold pathogens linger in the meridians causing unresolved chills and fever and a floating, soft pulse, the main formula is Huangqi Jianzhong Tang (Astragalus Middle-Nourishing Decoction) [Zhi Huang Qi, Gui Zhi, Bai Shao, Zhi Gan Cao, Sheng Jiang, Da Zao].
After Shanghan exterior symptoms resolve but Spleen Qi is deficient, allowing heat to sink vacuously and causing fetal restlessness, the main formula is Antai San (Fetal-Stabilizing Powder) [Sheng Bai Zhu, Huang Qin, Chao Bai Shao equal parts powdered; taken with decoction of Sheng Jiang and Da Zao]. For cases with tidal fever, the main formula is Antai Ejiao San (Fetal-Stabilizing Donkey-Hide Gelatin Powder) [Chao Ejiao, Dang Shen, Bai Zhu, Fu Ling, Sang Ji Sheng powdered; taken with rice water].
For pregnancy Shanghan invading the exterior and damaging Ying, causing headache, fever, aversion to cold, body pain, fetal restlessness, and a floating-tight choppy pulse, the main formula is Qianghuo San (Notopterygium Powder) [Qiang Huo, Sheng Bai Zhu, Fang Feng, Chao Bai Shao, Huang Qin, Dang Gui, Bai Zhi, Chuan Xiong, Gan Cao powdered; decocted and taken warm].
For pregnancy Shafeng, where wind pathogens invade meridians vacuously causing body heat, spontaneous sweating, fatigue, aversion to wind, fetal restlessness, and a floating-moderate pulse, the main formula is Huangqi Jiexi San (Astragalus Muscle-Relieving Powder) [Ren Shen, Huang Qi, Dang Gui, Chao Bai Shao, Chuan Xiong, Zhi Gan Cao powdered; taken with Zi Su Tang].
For pregnancy with insufficient Ying Blood and cold invading meridians causing body pain, absence of sweating, fever, aversion to cold, and a floating-weak pulse, the main formula is Guizhi Shaoyao Tang (Cinnamon Twig Peony Decoction) [Gui Zhi, Shao Yao, Dang Gui, Sheng Jiang, Cong Tou].
After pregnancy Shanghan exterior resolves but interior harmony is lost, causing abdominal pain, diarrhea, fetal restlessness, and a deep pulse, the main formula is Shaoyao Tang (Peony Decoction) [Chao Bai Shao, Chao Bai Zhu, Fu Ling, Zhi Gan Cao].
After pregnancy Shanghan exterior resolves but interior disharmony causes heat-coupled diarrhea, fetal unrest, and a rapid pulse, the main formula is Jiawei Huangqin Tang (Modified Scutellaria Decoction) [Chao Bai Shao, Chao Bai Zhu, Huang Qin, Fu Ling, Chao Ejiao, Zhi Gan Cao].
For pregnancy Shanghan with unresolved fire depression, damaged Ying Yin, damp-heat complication, purple-black macules, fetal unrest, and a rapid-string-taut-large pulse, the main formula is Zhizi Daqing Tang (Gardenia Great Green Decoction) [Xian Sheng Di, Sheng Ma, Jiao Zhi Zi, Xian Da Qing, Huang Qin, Cong Tou].
For pregnancy Shanghan with heat stagnating in Yangming, extreme heat causing purple-black macules, and a surging-rapid pulse, if not treated urgently, fetal death is imminent; the main formula is Qingdai Shigao Tang (Indigo Gypsum Decoction) [Zhen Qing Dai, Xian Sheng Di juice, Sheng Shi Gao, Sheng Ma, Huang Qin, Jiao Zhi Zi, Cong Tou].
After pregnancy Shanghan, residual heat obstructs the diaphragm, blood and Qi are secretly depleted, tidal fever persists, fetal unrest occurs, and the pulse is rapid-soft-string-taut, the main formula is Huanglong Siwu Tang (Yellow Dragon Four Substances Decoction) [Xian Sheng Di, Dang Shen, Huang Qin, Bai Shao, Chai Hu, Dang Gui, Chuan Xiong, Gan Cao].
After pregnancy Shanghan sweating, residual heat sinks internally, Wei Qi has no resting place, leakage sweating persists, fetal unrest occurs, and the pulse is floating-rapid, the main formula is Jiawei Danggui Liuhuang Tang (Modified Angelica Six Yellow Decoction) [Da Sheng Di, Qing Zhi Di Gu Pi, Chao Bai Shao, Zhi Gan Cao, Huang Qin, Bai Zhi, Dang Gui, Chao Ejiao, Fu Xiao Mai].
After pregnancy Shanghan sweating and purging, fluids are suddenly exhausted, empty irritability and insomnia occur, fetal unrest happens, and the pulse is soft-rapid, the main formula is Jiawei Zhuye Tang (Modified Bamboo Leaf Decoction) [Dan Zhu Ye, Bei Sha Shen, Xian Sheng Di, Mai Dong, Chao Ejiao, Zhi Gan Cao].
For pregnancy Shanghan where extreme heat damages Ying and the Blood Chamber is diseased, threatening the fetus, Xu Huixi advocated using 8 liang of Baoyaoshi (White Medicinal Earth/Litharge?) ground into powder, mixed with egg white, applied on oil paper to the lower abdomen over the fetus, moistening with water when dry, to detoxify, moisten dryness, and protect the fetal origin. Ye Tianshi also stated that for pre-pregnancy diseases, protecting the fetus is paramount to prevent pathogenic harm. If heat is extreme, well-bottom mud soaked in blue cloth can be applied to the umbilical/abdominal area, another method to protect the fetal origin. However, one must assess if the pathogen can be resolved before using these. If blood-nourishing cloying medicines fail, one must examine if purgation is indicated and stop once effective, without rigid adherence to fixed methods, always protecting the fetal origin to prevent righteous Qi damage and pathogen sinking.
[Xiu's Commentary]
The treatment of pregnancy Shanghan is already fully discussed previously, so no further repetition is needed. For syndromes of excessive pathogenic heat, one must not rigidly adhere to precedents by administering cloying fetal-stabilizing medicines, which would aid pathogenic heat and damage the fetal origin. As the Classic states: "If there is a cause/pathogen, there is no destruction [of the mother], nor destruction [of the fetus]." One should not attack large accumulations and aggregations lightly; stop when half is diminished, otherwise it kills. This is the key principle for treating pregnancy Shanghan. Wu Keyke stated that for pregnant women with Shanghan or epidemic febrile diseases, if Three Chengqi Decoctions are indicated, they must be administered according to the syndrome. Do not be confused by theories of Ren Shen, Bai Zhu, and Ejiao. Patients may panic upon seeing Chengqi Decoction used, causing hesitation that hinders the physician, bringing great misfortune to mother and child. If purgation is indicated but tonics are used instead, pathogenic fire becomes congested, heat toxin intensifies, fetal unrest increases, Qi is consumed, and Blood is contested; how can the conception rely on this? Thus, the ancients used the metaphor of a hanging bell: if the beam rots, the bell must fall. Only by using Chengqi Decoction to expel pathogens, dissipating fire toxins, cooling inflammation, restoring Qi, can the fetus stabilize. In such cases, Da Huang is seen as a holy medicine for stabilizing the fetus, proving effective in practice, ensuring safety for both. If abdominal pain is like needle insertion and lower back pain like breaking, the fetus is about to miscarry; medication is futile. Even with Chengqi Decoction, only the disease can be cured and the mother saved. Ignorant people blame the physician for fetal loss. If asked whether Chengqi Decoction might damage the fetus before expelling pathogens, the answer is: Impacted feces and stasis-heat are matters of the intestines and stomach; the fetus attaches to the spine, outside the intestines/stomach, within the uterus. Medicine reaches the stomach first, clearing stasis-heat, allowing fetal Qi to relax and nourish itself, benefiting and harming in an instant. There is nothing to worry about. Just ensure the dose reduces the illness by 70-80%, leaving residual pathogens to heal naturally, avoiding overdose, as per the Classic: "Stop when half is diminished."
[Lian's Verification]
Zhou Danyan said: When a pregnant woman contracts warm pathogens, the fetus is injured by heat, inevitably leading to miscarriage, and the mother may also perish. In this critical moment, explain the situation to the family and urgently clear the heat to seek a chance of survival. Such treatment often prevents miscarriage, resulting in safety. As Qibo said: "If there is a cause, there is no destruction." This is true. Wu Keyke's hanging bell metaphor is even more pertinent. Ultimately, whether the fetus is expelled or not, it may miscarry. However, if expelled, the mother has a 20-30% chance of survival; if not, the mother dies, and the fetus cannot survive alone. In severe warm diseases with dry red tongue and black/scoriated coating, heavy doses are needed to save life. In purgatives, remove Mang Xiao (Mirabilite) to avoid fetal damage. If the fetus is dead in utero with a cyan-black tongue, Mang Xiao is necessary to expel the dead fetus. Declare this clearly to the family to avoid slander.
[Rongzhai's Commentary]
Ji Shouqiao, author of *Kechen Yihua*, diagnosed pregnancy Shanghan by differentiating syndromes and inspecting the tongue coating. He stated: "Pregnancy Shanghan and warm-heat diseases are hardest to manage; one must differentiate the tongue coating. Zhang Danxian's six rules in *Shejian* are famous theories to follow: (1) Early cold invasion with red tongue and white slippery coating requires mild sweating to release the exterior; if face and tongue are white with fever from excessive cold water intake (extreme yang turning to yin), use warming middle medicines. Misusing cooling agents for cold limbs and irritability leads to death. (2) Red face and yellow tongue after 5-6 days indicate interior syndrome requiring mild purgation to protect the fetus; yellow face and tongue indicate missed sweating with damp-heat entering interior, requiring clearing heat and promoting urination. (3) Black face and tongue indicate water-fire conflict; mother and child die regardless of months. Red face with slightly black tongue allows fetal preservation. Gray tongue indicates pathogen entering uterus, fetus unstable. Red face indicates root unharmed, requiring urgent purgation to save mother. (4) Red face and tongue in pregnancy Shanghan/warmth require sweating/purgation based on symptoms for safety. White face with red tongue indicates deficient maternal Qi, requiring mild warming/dispersing. Black face with red tongue is ominous; near term, child lives, mother dies. (5) Red face with purple tongue indicates alcohol toxicity; pale purple with green indicates yin syndrome with food retention, difficult to treat even with Zhishi Lizhong or Sini categories. Red face with cyan tongue indicates fetal death in utero; urgently use Xionggui Tang combined with Pingwei San plus Piao Xiao to save mother. (6) Black face with dry/curling short tongue or yellow-black thorny cracked tongue indicates urgent interior syndrome; failure to purge harms fetus, purging risks immediate danger; without 'seeking clothes' or staring symptoms, 1-2 in 10 may be saved.' For pregnancy Shafeng, first stabilize fetus and smooth Qi. Even with tight pulse and no sweating, avoid Mahuang, Qinglong, and strong exterior-releasing agents due to ascending nature of wind herbs harming fetal Qi. Zheng Xugu said: 'For pregnancy Shafeng, regardless of month, Yan's Zisu Yin with Cong Bai is safest.' Ji was from Xiushui County, Qing Dynasty. Lu Dingpu called him 'deeply versed in medical principles, especially gynecology, diagnosing pregnancy/birth cases for 20+ years, saving 7-8 in 10 critical cases.' Thus, he was a reliable gynecological expert."