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Question: A woman who has recently given birth may suffer from three diseases. The first is Jing disease (a condition characterized by stiffness of the neck and back, and opisthotonos), the second is Yumao disease (a condition characterized by dizziness and blurred consciousness), and the third is difficulty in defecation. What is the reason for this?

The Master said: After recent childbirth, there is a deficiency of Yin blood, excessive sweating, and susceptibility to wind pathogenic factors, which leads to Jing disease. Loss of blood followed by sweating, with an excess of cold, leads to Yumao disease. Consumption of body fluids and dryness in the stomach leads to difficulty in defecation.

The four sentences "A woman who has recently given birth may suffer from three diseases" should be text from ancient medical classics. Zhang Zhongjing used a question-and-answer format to clarify the etiology of these three diseases. "What is the reason?" means, what causes Jing disease, Yumao disease, and difficulty in defecation? The following three paragraphs are direct answers to these questions. The text states "A woman who has recently given birth may suffer from three diseases," clearly indicating that these are not chronic conditions present before childbirth, but result from the sudden deficiency of blood caused by recent childbirth. When Yin blood is insufficient, it cannot retain Yang Qi, instead forcing Yin fluids to escape outward, leading to excessive sweating. The Liver stores blood and governs the sinews and vessels, and its element corresponds to Wind-Wood. Blood deficiency leads to internal wind stirring, which easily attracts similar external wind, making one susceptible to wind pathogens. Once the wind pathogen enters, it causes stiffness and tension of the sinews, resulting in Jing disease. Cold stagnation causes Qi mechanism depression, and wind rising causes dizziness and clouding of the mind; this is the cause of Yumao disease. Yumao arises from blood loss and subsequent sweating, related to wind strike. However, the blood loss here is more severe than general blood deficiency, and the cold is mostly cold carried by the wind. If wind strike occurs with cold exceeding wind, it leads to Yumao. Body fluids are governed by the Stomach. Blood deficiency and sweating cause massive damage to body fluids. Since the upper source is dried up, the lower flow naturally becomes dry, leading to stomach dryness and intestinal withering, thus causing difficulty in defecation. Summarizing these three diseases, the total cause is blood deficiency. Only women after recent childbirth experience such sudden blood deficiency, hence these three diseases occur.

When a postpartum woman presents with Yumao symptoms, the pulse is faint and weak, she cannot eat, her stool is hard, and only her head sweats. This is because blood deficiency leads to Jue (reversal of Qi and blood flow), and Jue inevitably leads to Mao (dizziness/clouding). For Yumao to resolve, there must be profuse sweating over the whole body. Because blood is deficient at the lower jiao leading to Jue, solitary Yang rises alone, so only the head sweats. Therefore, postpartum women tend to sweat because losing Yin blood leads to blood deficiency and solitary excess of Yang. Sweating allows the harmonization of Yin and Yang, restoring balance. If the stool is hard and eating is impossible, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is indicated. If the illness resolves and she can eat, but fever returns after seven or eight days, this indicates Excess Heat in the Stomach (Wei Shi), treated with Da Cheng Qi Tang (Major Order the Qi Decoction).

This section further elaborates on the pulse and symptoms of Yumao, why Yumao does not resolve, and various symptoms appearing after resolution, determining the governing formulas. Postpartum Yumao differs from that of ordinary people. The pulse of Yumao can sometimes be large and strong, but now it is neither large nor small, neither strong nor weak, fitting the normal pulse of a postpartum woman, indicating that Zheng Qi (Upright Qi) has not yet failed and pathogens do not dominate. Mao implies rebellious Stomach Qi, hence inability to eat. Depression causes Spleen Qi to sink, usually leading to loose stools, but due to blood deficiency and fluid injury causing stomach dryness, the stool is hard. Blood deficiency at the lower jiao and Qi excess at the upper jiao result in Yin failing to control Yang and Yang failing to secure, causing only head sweating. Specifically, blood belongs to Yin and nourishes Yang; blood deficiency causes Yang to sink inward leading to Jue. Jue refers to cold extremities. Qi belongs to Yang and nourishes Yin; sweating causes Yin to escape outward leading to Mao. Mao refers to mental clouding. Fortunately, the pulse is faint and weak, indicating pathogens have not overwhelmed Zheng Qi. In this difficult situation of attacking vs. tonifying, do not treat rashly. Wait for the Qi phase to pass and blood to return, allowing Yin and Yang to reconnect. As Qi no longer stirs blood upward, blood returns and guides Qi downward, allowing sweating to resolve Yumao. This is the process of Yumao starting with Jue and ending with sweating. Although head sweating resembles indications for purgation, it is not so. Postpartum blood deficiency causes lower jiao cold and Jue; solitary Yang lacks attachment, causing upper jiao heat steaming upward, hence head sweating. Misdiagnosing this and using purgation early would be dangerous. Yumao does not resolve with head sweating but requires whole-body sweating because postpartum blood loss leaves blood temporarily deficient, allowing Yang to grow solitary and excess, manifesting as external depression. Yin deficiency fails to send Yang out, causing self-depression. Spontaneous sweating indicates Yin generation and Yang release, restoring Yin-Yang balance. Once Yumao resolves, if constipation and vomiting/inability to eat persist, initially use Xiao Chai Hu Tang to clear rebellious Heat Qi, stopping vomiting and restoring appetite. If fever returns after seven or eight days, it is due to food accumulation causing Wei Shi (Stomach Excess) steaming outward. Then Da Cheng Qi Tang can be safely used for purgation.

Postpartum abdominal pain is treated with Dang Gui Sheng Jiang Yang Rou Tang (Angelica Ginger Mutton Decoction). It also treats abdominal Han Shan (Cold Hernia) and Xu Lao (Deficiency Consumption) insufficiency. (Dang Gui Ginger Mutton Decoction is mentioned elsewhere.)

This is abdominal pain due to empty Qi and deficient blood. Empty Qi means the uterus has just delivered, and the intestines and stomach are unsettled, causing hollow pain. Blood deficiency causes collaterals to dry and contract, causing pulling pain. Dang Gui is bitter and warm to tonify blood; Ginger and Mutton are pungent-warm and sweet-warm to tonify Qi, ensuring even distribution of Yang Qi and moistening of Yin blood, making them the main analgesic herbs. Warming the upper transforms lower cold; tonifying the upper secures lower slipping. Thus, it treats Cold Hernia invading the abdomen and seminal emission/slippage from Deficiency Consumption.

Postpartum abdominal pain with irritability, fullness, and inability to lie flat is treated with Zhi Shi Shao Yao San (Immature Bitter Orange and Peony Powder).

Zhi Shi Shao Yao San Formula: Zhi Shi (burned until black but not too much), Shao Yao (equal parts).
Crush the two ingredients into a powder. Take one cun bi (measure) per dose, three times daily. It also treats carbuncles and pus. Administer with wheat porridge.

This addresses symptoms where abdominal blood is suddenly deficient and Ke Qi (pathogenic factor) lingers in the blood level. The abdomen is Yin; abdominal blood level is Yin within Yin. Taking advantage of deficiency, Ke Qi stays in empty spaces, causing pain and fullness. Pain prevents Yang Qi from settling internally; fullness makes breathing difficult to guide downward, causing inability to lie flat. Zhi Shi breaks stagnant Qi; burning it black enters the Yin level to break blood stasis. Combined with Shao Yao, which moves blood, it penetrates directly into Yin-blood without deviation, hence it is indicated. Wheat porridge likely refers to wheat, as wheat is the grain of the Heart, suitable for blood deficiency and treating irritability in symptoms. Carbuncles and pus also form from Ke Qi lingering in the blood level, hence treated here. For those in the meridians, Mahuang-Guizhi type herbs might be added to guide outward, or Dang Gui-Xiong type herbs to disperse and move. "Mainly treat" implies using this as the primary formula while allowing modifications.

The Master said: Postpartum abdominal pain should primarily be treated with Zhi Shi Shao Yao San. If it does not heal, it is because dry blood is adhering below the umbilicus. Xia Yu Xue Tang (Downward Expel Blood Decoction) is indicated. It also treats irregular menstruation.

Xia Yu Xue Tang Formula: Da Huang (3 liang), Tao Ren (30 seeds), E Chong (20 pieces, roasted and feet removed).
Grind the three ingredients into powder. Mix with refined honey to make four pills. Decoct one pill in one sheng of wine to obtain 8 he of liquid. Take all at once. Expelled blood will resemble pig liver.

Postpartum abdominal pain has only two causes: Qi stagnation and Blood stasis. If Zhi Shi-Shao Yao San fails, it is not Qi stagnation but Blood stasis pain, hence Xia Yu Xue Tang is needed to purge stasis. Using heavy blood-breaking Tao Ren combined with E Chong, which travels through collaterals to move blood, reaches the site of stasis directly. Then Da Huang, heavy in flavor and nature and skilled at attacking blood, acts as the sovereign herb to drive it down. Decocting in wine and taking once leverages rapid action and combined force. Irregular menstruation is not caused by the twelve main meridians but by fine collaterals irrigating the Blood Chamber being blocked by stasis, or fine collaterals connecting the Blood Chamber to Yaoshu being obstructed by dry blood. Hence this formula works; removing stasis restores regular menstruation.

Seven or eight days postpartum, without Taiyang symptoms, the lower abdomen is hard and full, indicating incomplete expulsion of lochia. Constipation, irritability, and fever are present. The pulse is slightly solid. Fever doubles. Irritability worsens at dusk (Shen-You hours). Inability to eat; eating triggers delirium. Symptoms improve at night. Da Cheng Qi Tang (Major Order the Qi Decoction) is indicated. Heat is in the interior; binding is in the Bladder region.

The previous second paragraph elaborated on Yumao; the later seventh and eighth paragraphs elaborate on treatments for wind strike, likely to prevent complications. This paragraph discusses variations of difficulty in defecation. Thus, preceding symptoms center on "constipation." Postpartum blood deficiency causes dry intestines and constipation. After seven or eight days of constipation, intestinal exuberance and Qi stagnation occur. Qi stagnation prevents lochia discharge, creating crises. Lochia retention is caused by constipation. Without purgation to unblock Qi and move blood, treatment is impossible. However, postpartum patients are inherently deficient; diagnosis must be absolutely certain before using purgatives. Otherwise, violating the prohibition against "deficient-deficient" (weakening the weak) accelerates death. For example, seven or eight days postpartum, food was consumed, yet there are no Taiyang headache/chills symptoms, ruling out wind-cold. There should be no exterior irritability/fever. Now, lower abdomen hardness/fullness indicates that during these days, food intake without defecation caused Qi stagnation blocking blood, leaving lochia bound in the lower abdomen. Constipation causes lower dryness to absorb essence upward, causing irritability. Interior excess pushes outward to meridians, causing fever. One dare not purge immediately; the pulse must be slightly solid, indicating internal Qi aggregation. Doubled fever indicates prolonged internal binding increasing heat. Dusk irritability corresponds to the peak time of Hand-Foot Yangming Fire (Shen-You hours). Inability to eat reflects intestinal/stomach excess rejecting food. Eating triggers delirium because fluids are dry and food blocks the pathway for Shen Qi circulation. Day is Yang, governing Fu organs; Night is Yin, governing Zang organs. Disease in Hand-Foot Yangming involves Stomach and Large Intestine Fu organs, worsening during the day. Unrelated to Yin Zang organs, improving at night. Based on these pulses and symptoms, using Da Cheng Qi Tang is justified. "Heat in the interior" echoes "no Taiyang symptoms"; "Binding in the Bladder" echoes "lower abdomen hardness/fullness." This means interior heat steams outward, causing fever without Taiyang wind-cold. Interior heat-excess causes lochia blood to bind behind the Bladder, causing lower abdomen hardness/fullness. Both fall under purgation categories. "Binding in the Bladder" should not be taken literally as inside the Bladder, but rather the space adjacent behind it. The two intestines lead to defecation, located posteriorly; the Bladder floats anteriorly in the lower abdomen. Postpartum blood originates from the womb, providing lubrication for the fetus. After delivery, blood has nowhere to go, so it exits via the path between the intestines and Bladder, becoming lochia. Lochia binds in the lower abdomen because the Large Intestine is slightly below the Bladder. Large Intestine heat-excess stagnates Qi moving blood and compresses orifices, trapping blood behind the Bladder, opposite the Bladder, though indescribable, so the Bladder serves as an outer reference. Careful observation clarifies this. Li's old annotation from Qiantang erroneously borrows Shanghan Lun text, a misunderstanding beyond imagination.

Postpartum wind strike persists for dozens of days without relief, with mild headache, chills, intermittent fever, chest oppression, dry retching, and prolonged sweating. Yang Dan Tang symptoms remain. Yang Dan Tang (Yang Shield Decoction) can be administered.

Postpartum excessive sweating leading to wind strike forming malaria-like symptoms is common. However, some with sufficient daily fluids only get wind strike without malaria-like symptoms. Persistence for dozens of days matches the headache, chills, fever, and sweating of Yang Dan Tang's primary syndrome. Chest oppression and dry retching reflect Stomach Qi deficiency-cold and obstruction, secondary symptoms of Yang Dan Tang. Even after dozens of days, wind remains, so Yang Dan Tang is appropriate. Meaning explained in Shanghan Lun. With chest oppression and dry retching, add Ginger and Banxia to the original decoction. Calling it "can give Yang Dan Tang" implies a lighter, halved dose for mild sweating. Observing efficacy after dozens of days suggests initial wind strike and subsequent malaria-like symptoms are also managed by this decoction.

Postpartum wind strike with fever, bright red face, wheezing, and headache is treated with Zhu Ye Tang (Bamboo Leaf Decoction).

Zhu Ye Tang Formula: Zhu Ye (1 bundle), Ren Shen (1 liang), Fu Zi (1 piece, processed), Gui Zhi (1 liang), Ge Gen (3 liang), Fang Feng (1 liang), Jie Geng (1 liang), Gan Cao (1 liang), Sheng Jiang (5 liang), Da Zao (15 pieces).
Ten ingredients. Decoct in 1 dou of water to obtain 2.5 sheng. Divide into three warm doses. Cover warmly to induce sweating. For stiff neck, use 1 large Fu Zi, broken bean-sized, decocted. Skim foam. For vomiting, add 0.5 sheng washed Banxia.

This wind strike differs from the previous case. The previous case involved wind pathogen solely in Taiyang exterior, with Stomach deficiency-cold but no transmission, treated with Yang Dan Tang plus Ginger/Banxia to resolve Taiyang wind and warm/descend. This case involves inherent Yang deficiency-cold, allowing wind to enter Taiyang and transmit to Yangming channels/organs, accompanied by fluid retention in the Stomach, while Taiyang exterior signs persist. Persistent Taiyang signs cause ongoing headache. Yang pathogen transforming into deficiency-heat in the Stomach manifests as bright red face (Yangming correspondence). Fluid retention steaming upward affects Lung moisture, causing wheezing. Two Yang pathogens, unable to be expelled due to Yang deficiency, cause fever. Understanding these symptoms reveals the decoction's logic. Ge Gen, Gui Zhi, Gan Cao, Ginger, and Jujube in this formula constitute Ge Gen Tang (Kudzu Decoction) for Yangming channel. Ge Gen Tang uses Stomach fluids to generate muscle-releasing sweat without damaging Stomach fluids, serving as the base. Stomach deficiency-heat is unsuitable for bitter-cold herbs; thus, cool Zhu Ye is used to lightly dissipate heat. Yang deficiency-cold cannot expel pathogens; thus, Ren Shen and Fu Zi are doubled to warm and tonify. Wind and fluid retention are constrained; Jie Geng lifts and opens. Postpartum deficiency plus induced sweating risks re-exposure to wind; Fang Feng secures the exterior. Stiff neck indicates Yang softness failing to nourish sinews; replace small Fu Zi with large Fu Zi for added strength. "Use" implies replacing, not adding. Skimming foam reduces Fu Zi's ascending nature and prevents aggravating facial redness/vomiting. Banxia descends rebellious Qi, added for vomiting. The first paragraph listed three postpartum diseases: Yumao and constipation detailed in paragraphs 2 and 6. Paragraphs 7 and 8 discuss wind strike without mentioning malaria-like symptoms, likely because their treatments are detailed elsewhere in this chapter.

During lactation, a woman suffers from middle-jiao deficiency, irritability, restlessness, cough, and counterflow qi. An Zhong Yi Qi Wan (Peace the Middle and Tonify Qi Pill) is indicated.

Zhu Pi Da Wan Formula: Sheng Zhu Ru (2 fen), Bai Wei (1 fen), Gui Zhi (1 fen), Shi Gao (2 fen), Gan Cao (7 fen).
Five ingredients. Grind into powder. Mix with date paste to form pills the size of a bullet. Take one pill with water, three times daily, twice at night. For heat, double Bai Wei. For irritability/wheezing, add Bo Shi (Cupressus fruit) 1 fen.

"Lactation" refers to nursing. "Middle deficiency" refers to Yin fluids and Yang Qi in the epigastrium. Milk derives from Stomach Yin fluids, floating up through epigastric collaterals to breasts. Nursing draws essence, causing solitary Yang heat excess, leading to temporary epigastric dryness and irritability. Nursing also empties Diaphragm Qi, allowing lower Qi to rebel, causing cough and counterflow. This is not a new postpartum or severe postpartum condition. Women with inherent Yang excess often experience this 2-3 months to over a year postpartum, especially during milk let-down, feeling anxious thirst. Sweet-cold and pungent-cool herbs nourish Yin and suppress Yang, calming the middle and resolving irritability. Pungent-warm and sweet-flat herbs tonify the upper to resist the lower, boosting Qi and stopping cough. Zhu Pi Da Wan achieves this. Bamboo grows evergreen; Viola roots remain flexible long-term, showing their ability to nourish Yin fluids beyond mere bitter-cold heat-clearing. Paired with pungent-cool Shi Gao, they act like gentle rain/wind, moistening dryness and clearing heat, achieving "peace the middle." Gui Zhi is pungent-warm, generating Yang. Paired with heavy Gan Cao (7x), it lifts Qi to the upper/middle, like sunrise dispelling Yin mist, preventing counterflow cough. This is "tonifying Qi." Date paste pills reinforce Gan Cao's role, lifting herbs to treat the upper. "Middle deficiency" refers to the epigastrium piercing the diaphragm. Large pills chewed allow quick release and less residue retention. Five doses daily ensure slow nourishment and continuous effect. Bai Wei is bitter-cold, clearing heat; doubled for heat. Cypress fruits, enduring winter, receiving Metal energy, are sweet-flat, soothing the middle and descending rebellion; added for middle deficiency irritability and Lung rebellion wheezing. Original formula had 13 parts; doubling Bai Wei and adding Bo Shi makes 15 parts.

Postpartum diarrhea with extreme exhaustion is treated by Bai Tou Weng Jia Gan Cao E Jiao Tang (Pulsatilla Decoction with Licorice and Donkey-Hide Gelatin).

Bai Tou Weng Jia Gan Cao E Jiao Tang Formula: Bai Tou Weng (2 liang), Qin Pi (3 liang), Huang Lian (3 liang), Huang Bo (3 liang), Gan Cao (2 liang), E Jiao (2 liang).
Six ingredients. Decoct in 7 sheng of water to obtain 2.5 sheng. Dissolve E Jiao. Divide into three warm doses.

This is a syndrome of Liver Blood failing to store and Liver Yang leaking recklessly. Postpartum blood deficiency typically causes hard stool; heat binding in the Large Intestine due to hardness leads to extreme heat causing paralytic diarrhea (this is the branch). Blood is stored in the Liver; Liver secretes bile to irrigate intestines, ensuring normal bowel movements. Postpartum blood deficiency leaves the Liver without blood to store, and Liver Yang's irritable Qi flows through the gallbladder duct into the intestines, causing abdominal pain, tenesmus, and urgent desire to defecate with little output. This diarrhea stems from postpartum blood deficiency. Straining during diarrhea further injures Qi, leading to extreme exhaustion (blood deficiency compounded by Qi exhaustion). Zhang Zhongjing identifies the root as blood deficiency and Liver Yang hyperactivity, directly prescribing Bai Tou Weng Jia Gan Cao E Jiao Tang. Bai Tou Weng Tang notes are in Shanghan Lun Jueyin diarrhea. Adding Gan Cao and E Jiao soothes the middle and tonifies blood. "Mainly treat" allows modification but not substitution. For bloody diarrhea, add Dang Gui; for white mucus, add Bai Shao; for Qi stagnation/scanty urine, add Zhi Shi and Che Qian Zi. These adjustments depend on the physician's discretion.