【纲】仲景曰。太阳病。过经十余日。反二三下之。后四五日。柴胡症仍在者。先与小柴胡汤。
呕不止。心下急。郁郁微烦者。为未解也。与大柴胡汤。则愈。
【目】李 曰。伤寒六日传经已遍。七日当解。至十三日以上不愈。谓之过经。汗下失宜。以
致邪气流连不已。神昏谵语。胸满潮热。随其表里症见而调之。或从轻再汗再下。如脉乱发躁。尺
寸陷者。危。如脉缓安睡。邪未尽者。正未复耳。参胡芍药汤调之。有大便下利而脉和者。诸医以
丸药下之。停留余热。凡过经气虚。或加异气。宜与外症参看。
喻昌曰。过经不解者。由七八日已后。至十三日已后。过一候二候。犹不痊解也。然邪在身中
日久。势必结聚于三阳。太阳为多。少阳次之。阳明又次之。及至三阴。则生死反掌。不若此之久
持矣。
程郊倩曰。过经十余日而不知太阳症有未罢。反二三下之。因致变者多矣。后四五日。柴胡症
仍在。未有他变。本当行大柴胡两解表里。但其邪屡因误下而深入。即非大柴胡下法所能服。故必
先用小柴胡提其邪出半表。然后乃用大柴胡。始合法也。
【纲】仲景曰。太阳病。过经十余日。心下温温欲吐。而胸中痛。大便反溏。腹微满。郁郁微
烦。先此时自极吐下者。与调胃承气汤。若不极者。不可与。但欲呕。胸中痛。微溏者。此非柴胡
症。以呕故知极吐下也。
【目】喻昌曰。此条有二辨。若曾经大吐下者。邪从吐解。直已入里。可用调胃承气之法。若
未经吐下。但欲呕。胸中痛微溏者。是痛非吐所伤。溏非下所致。调胃之法。不可用矣。岂但调胃不
可用。即柴胡亦不可用。以邪尚在太阳高位。
徒治阳明少阳。而邪不解耳。解太阳之邪。仲景言之已悉。故此但示其意也。若其人能呕。则是为吐
下所伤。而所主又不在太阳矣。
【纲】仲景曰。伤寒十三日不解。胸胁满而呕。日晡所发潮热。已而微利。此本柴胡症。下之而
不得利。今反利者。知医以丸药下之。非其治也。若自下利者。脉当微厥。今反和者。此为内实也。
调胃承气汤主之。
【目】喻昌曰。二条俱见微利之症。难辨其内虚内实。上条。胸胁满而呕。邪凑少阳之表。故
欲下之。必用柴胡为合法。若以他药下之。表邪内入。即是内虚。此条。原无表症。虽丸药误下。
其脉仍和。即为内实也。按仲景下法。屡以丸药为戒。惟治太阳之脾约用麻仁丸。因其人平日津枯
肠结。必俟邪入阳明下之。恐无救于津液。故虽邪在太阳。即用丸药之缓下润其肠。俾外邪不因峻
攻而内陷也。此等处亦须互参。再按伤寒以七日为一候。其有二三候不解者。病邪多在三阳经留恋。
不但七日传之不尽。即十三日二十余日。尚有传之不尽者。若不辨症。徒屈指数经数候。汗下展
转差误。正虚邪凑。愈久愈难为力。所以过经不解。当辨其邪在何经而取之。仲景云。太阳病头痛
至七日以上自愈者。以行其经尽故也。即内经七日太阳病衰头痛少愈之旨可见。太阳一经。有行之
七日以上者。其欲再作经者针足阳明。使经不传则愈。以太阳既羁留多日。则阳明少阳亦可羁留。
过经漫无解期矣。所以早从阳明中土而夺之。俾其不传。此捷法也。若谓六经传尽。复传太阳。必无
是理。后人坠落成无己阱中耳。岂有厥阴两阴交尽于里。复从皮毛外再入太阳之事耶。请破此大惑。
【纲】张仲景说：太阳病（太阳经受邪所致的病证），病程超过经界十余日，反而被使用了二三次攻下法。此后四五日，如果小柴胡汤证（少阳病的主要证候）仍然存在，先给予小柴胡汤（和解少阳的代表方剂）。
如果出现呕吐不止、胃脘部拘急疼痛、心中郁郁不舒且轻微烦躁的症状，说明病邪尚未解除，应给予大柴胡汤（和解少阳、内泻热结的方剂），这样就能痊愈。
【目】李氏说：伤寒病六天传遍六经，第七天应当痊愈。到了十三日以上仍不愈，称为“过经”。这是因为发汗和攻下不当，导致邪气留恋不去，出现神志昏沉、胡言乱语、胸中胀满、定时发热等症状。应根据表里症状的表现来调理。或者从轻再行发汗或攻下。如果脉象紊乱、烦躁不安、尺部脉搏陷下的，属于危重证候。如果脉象缓和、安静嗜睡，说明邪气未尽，只是正气未恢复而已。可用参胡芍药汤进行调理。如果有大便下利但脉象平和的，这是其他医生用丸药攻下所致，余热停留体内。凡是过经后气虚，或夹杂其他病邪的，应当结合外在症状综合判断。
喻昌说：所谓“过经不解”，是指过了七八天以后，直到十三天以后，经过一个或两个七天周期，仍然没有痊愈。然而邪气在体内日久，势必结聚在三阳经，以太阳经为多，少阳经次之，阳明经又次之。一旦传入三阴经，则生死只在顷刻之间，不像此病那样持久拖延。
程郊倩说：过经十余日而不知道太阳病的症状尚未罢休，反而用了二三次攻下法，因此导致变证的很多。过了四五日，小柴胡汤证仍然存在，没有其他变证，本应当使用大柴胡汤双解表里。但是邪气屡次因误用攻下而深入体内，此时已不适合直接使用大柴胡汤的下法。所以必须先用小柴胡汤将邪气从半表半里提出，然后再用大柴胡汤，这才符合治疗法则。
【纲】张仲景说：太阳病，病程超过十余日，患者感到胃脘部恶心欲吐，且胸中疼痛，大便反而稀溏，腹部轻微胀满，心中郁郁不舒且轻微烦躁。如果在这些症状出现之前，病人曾经接受过剧烈的催吐或攻下治疗，应给予调胃承气汤（缓下热结的方剂）。如果没有经历过剧烈吐下，则不可给予此方。如果只是想呕吐、胸中痛、大便微溏，这不是小柴胡汤证，而是因为呕吐可知其曾受剧烈吐下损伤。
【目】喻昌说：这一条有两个辨析点。如果曾经接受过大吐大下，邪气随吐而解，直接入里，可以使用调胃承气汤的方法。如果未曾吐下，只是想要呕吐、胸中痛、大便微溏，那么胸痛并非由吐伤引起，便溏也不是由下法导致，调胃承气汤的方法就不可使用了。岂止是调胃承气汤不可用，就连小柴胡汤也不可用，因为邪气尚在太阳经的高位。只治疗阳明、少阳，邪气是无法解除的。解除太阳经邪气的方法，张仲景已经讲得很详细了，所以这里只是示意其意。如果病人能够呕吐，那就是被吐下所伤，主治方向就不在太阳经了。
【纲】张仲景说：伤寒病十三天仍未痊愈，胸胁部胀满且呕吐，每天傍晚时分出现定时发热，随后出现轻微腹泻。这原本是小柴胡汤证，经过攻下治疗后没有得到腹泻。现在反而出现腹泻，可知医生使用了丸药攻下，这不是正确的治疗方法。如果是自然腹泻，脉象应当微弱厥冷，现在脉象反而平和，这说明体内有实邪积滞。应以调胃承气汤为主治方剂。
【目】喻昌说：这两条都出现了轻微腹泻的症状，难以辨别是内虚还是内实。上一条，胸胁胀满且呕吐，邪气凑集于少阳之表，所以要攻下，必须用小柴胡汤才合法度。如果用其他药物攻下，表邪内陷，就是内虚。这一条，原本没有表证，虽然被丸药误下，但脉象仍然平和，这就是内实证。按张仲景的下法，多次告诫不要用丸药。只有治疗太阳经脾约证时使用麻仁丸，是因为病人平日津液枯竭、肠道干结，必定要等到邪气进入阳明经时再攻下，恐怕无法挽救津液。所以即使邪气在太阳经，也使用丸药缓慢润肠，使外邪不因猛烈攻下而内陷。这些地方也需要互相参照。另外，按伤寒论以七天为一个周期（一候），如果有两三个周期仍未解的，病邪多留恋在三阳经。不仅仅是七天传不完，即使是十三天、二十多天，还有传不完的。如果不辨证候，只是屈指数算经络和周期，发汗和攻下就会辗转出错，导致正气虚弱、邪气凑集，时间越久越难治疗。所以过经不解，应当辨别邪气在哪一经而进行治疗。张仲景说：太阳病头痛持续七天以上自愈的，是因为经气运行完毕的缘故。这也体现了《内经》中“七日太阳病衰，头痛稍减”的宗旨。太阳一经，有运行七天以上的，如果想让它不再传变，可以针刺足阳明经，使经脉不传变就能痊愈。因为太阳经既已羁留多日，那么阳明、少阳经也可能羁留，过经后漫无解脱期限。所以尽早从阳明中土截断病势，使其不传变，这是捷径。如果说六经传尽后又传回太阳，必然没有这个道理，这是后人落入成无己的陷阱罢了。怎么会有厥阴两阴交尽于里，又从皮毛重新进入太阳的情况呢？请破除这个大的疑惑。
[Outline] Zhang Zhongjing stated: In Taiyang disease, after the pathogen has passed through the meridians for more than ten days, if it is mistakenly treated with purgatives two or three times, and after another four to five days, the Chaihu syndrome (Bupleurum Syndrome) still persists, one should first administer Xiao Chaihu Tang (Minor Bupleurum Decoction). If there is incessant vomiting, epigastric urgency, and slight depression and vexation, the disease has not yet resolved; Da Chaihu Tang (Major Bupleurum Decoction) should be administered, leading to recovery.
[Commentary] Li stated: In Shanghan (Cold Damage), transmission through the meridians is completed in six days, and resolution should occur on the seventh day. If it remains unresolved beyond the thirteenth day, it is termed "Guojing" (Passing the Meridian Stage). Due to inappropriate sweating or purging, the pathogenic factor lingers, causing mental confusion, delirium, chest fullness, and tidal fever. Treatment should be adjusted according to the presenting exterior or interior symptoms. One may resort to mild re-sweating or re-purging. However, if the pulse is chaotic, restlessness is present, and the Cun and Chi pulses are sunken, the condition is critical. If the pulse is slow and the patient sleeps peacefully, but the pathogen remains, this indicates that the Zheng Qi (Upright Qi) has not yet recovered. Can Hu Shao Yao Tang (Ginseng, Bupleurum, and Peony Decoction) can be used for regulation. In cases of diarrhea with a harmonious pulse, other physicians may have used pill-based purgatives, leaving residual heat. Generally, when Guojing occurs with Qi deficiency, or when mixed with other pathogenic factors, external symptoms must be considered comprehensively.
Yu Chang stated: "Guojing bujie" (Unresolved after passing the meridian stage) refers to the period from after the seventh or eighth day up to after the thirteenth day, spanning one or two "Hou" (five-day periods), without recovery. Since the pathogen has remained in the body for a long time, it inevitably clusters in the Three Yang meridians, most commonly in Taiyang, followed by Shaoyang, and then Yangming. Once it enters the Three Yin meridians, life and death hang in the balance, unlike the prolonged nature of this condition.
Cheng Jiaoqian stated: After more than ten days of Guojing, if one fails to recognize that the Taiyang syndrome has not ceased, and mistakenly applies purgatives two or three times, many variations arise. Four to five days later, if the Chaihu syndrome persists without other changes, Da Chaihu Tang should theoretically be used to resolve both exterior and interior simultaneously. However, since the pathogen has deeply penetrated due to repeated erroneous purging, the purgative method of Da Chaihu Tang is no longer directly applicable. Therefore, Xiao Chaihu Tang must first be used to draw the pathogen out from the half-exterior/half-interior level, followed by Da Chaihu Tang, which conforms to the correct therapeutic principle.
[Outline] Zhang Zhongjing stated: In Taiyang disease, after passing the meridian stage for more than ten days, if there is nausea with a desire to vomit, chest pain, loose stools, slight abdominal fullness, and slight depression and vexation, and if prior to these symptoms the patient had undergone extreme emesis or purging, Tiao Wei Cheng Qi Tang (Regulate the Stomach and Direct the Qi Decoction) should be given. If such extreme emesis or purging did not occur, this formula is contraindicated. Symptoms limited to a desire to vomit, chest pain, and slightly loose stools do not constitute Chaihu syndrome; the vomiting indicates prior extreme emesis or purging.
[Commentary] Yu Chang stated: This passage requires two distinctions. If the patient previously underwent severe emesis and purging, the pathogen was resolved via emesis and entered the interior; thus, the method of Tiao Wei Cheng Qi Tang can be used. If no emesis or purging occurred, and there is only a desire to vomit, chest pain, and slight loose stools, the chest pain is not caused by emesis damage, nor is the loose stool caused by purging damage; therefore, the method of Tiao Wei Cheng Qi Tang is inapplicable. Not only is Tiao Wei Cheng Qi Tang inapplicable, but Xiao Chaihu Tang is also contraindicated, as the pathogen remains at the high position of the Taiyang meridian. Treating only Yangming and Shaoyang will not resolve the pathogen. Zhang Zhongjing has already detailed how to resolve Taiyang pathogens, so here he merely indicates the principle. If the patient can vomit, it indicates injury from emesis/purging, and the focus is no longer on the Taiyang meridian.
[Outline] Zhang Zhongjing stated: In Shanghan, after thirteen days without resolution, if there is chest and hypochondriac fullness with vomiting, tidal fever occurring in the late afternoon (You hour), followed by slight diarrhea, this originally presented as Chaihu syndrome. It was erroneously treated with purgatives, resulting in no initial diarrhea. Now, diarrhea has occurred; knowing that the physician used pill-based purgatives, this was an incorrect treatment. If the diarrhea were spontaneous, the pulse would be faint and cold (Jue); however, the pulse is now harmonious, indicating internal excess (Nei Shi). Tiao Wei Cheng Qi Tang should be the primary treatment.
[Commentary] Yu Chang stated: Both passages present symptoms of slight diarrhea, making it difficult to distinguish between internal deficiency and internal excess. In the first passage, chest and hypochondriac fullness with vomiting indicate the pathogen gathering at the exterior of Shaoyang; thus, purging is indicated, and using Chaihu Tang is correct. Using other purgatives causes the exterior pathogen to sink inward, resulting in internal deficiency. In the second passage, there was originally no exterior syndrome; despite erroneous purging with pills, the pulse remains harmonious, indicating internal excess. According to Zhang Zhongjing’s methods, pill-based purgatives are frequently cautioned against. The only exception is the use of Ma Ren Wan (Hemp Seed Pill) for Taiyang Pi Yue (Spleen Constraint), because the patient typically suffers from dry intestines and depleted fluids. Waiting until the pathogen enters Yangming for purging might fail to preserve fluids. Thus, even while the pathogen is in Taiyang, the mild laxative and moistening action of the pill is used to lubricate the intestines, preventing the exterior pathogen from sinking inward due to harsh attack. These points require cross-reference. Furthermore, in Shanghan, seven days constitute one "Hou." If unresolved after two or three Hou, the pathogen often lingers in the Three Yang meridians. Transmission is not necessarily complete in seven days; even after thirteen or twenty-plus days, transmission may continue. Without differentiating symptoms, merely counting meridians and Hou periods leads to errors in sweating and purging, causing Zheng Qi deficiency and pathogen accumulation, making treatment increasingly difficult over time. Therefore, in Guojing bujie, one must identify which meridian the pathogen resides in and treat accordingly. Zhang Zhongjing stated: Taiyang headache resolving after seven days occurs because the meridian circulation is complete, consistent with the Nei Jing’s principle that Taiyang disease declines and headache improves after seven days. For Taiyang, if it persists beyond seven days and one wishes to prevent further transmission, acupuncture of the Foot-Yangming meridian can stop transmission and promote recovery. Because Taiyang lingers for many days, Yangming and Shaoyang may also linger, extending the unresolved period indefinitely. Thus, early intervention at the Yangming Central Earth is necessary to intercept transmission; this is a swift method. To claim that after all Six Meridians are transmitted, the pathogen returns to Taiyang is illogical. This is a trap set by Cheng Wuji for later scholars. How could Jueyin, where two Yins meet and exhaust in the interior, re-enter Taiyang from the skin and hair? Please dispel this great confusion.