此人迎在结喉两旁，不在左手，四证也。又阴阳类论，黄帝以三阳之脉至手太阴。又曰：一阳者，少阳也。至手太阴，上连人迎。此即寸口以上察人迎，所谓人迎与寸口上下相应者是也。若以左为人迎，则上字无着落。若以左寸之上为人迎，则手太阴上连人迎，又作何说。手太阴，寸口也。既以左为人迎，右为寸口。寸口之上，又有人迎，是人迎又在右寸之上，更不得言左为人迎。又平人气象论曰：颈脉动喘疾咳曰水。颈脉即人迎也。此人迎在结喉两旁，不在左手，五证也。又《周礼》医师郑康成注，脉之大候，要在阳明寸口。贾公彦疏：阳明者，在大拇指本骨之高处，与第二指间。寸口者，大拇指本高骨后一寸是也。按：郑注，脉之大候，要在阳明寸口，阳明即胃之人迎，寸口即太阴肺脉，以二脉为百脉之根源，故为大要。贾疏，阳明在大拇指本骨之高处，与第二指间，乃阳明部所属之脉，即《素问·脉要精微论》右外以候胃是也。阳明属胃在右关外侧，故近第二指间，非阳明本部。阳明本部，即人迎脉也。在结喉两旁。寸口在大拇指本高骨后一寸乃尺中部位，即扁鹊、长沙，以两尺之下察寸口之意。大拇指本高骨为关脉，贾公彦但知两尺之下察寸口，不知两寸之上察人迎，故误以阳明本部在右关外侧，此亦人迎不在左手之一证。
《内经》本以人迎总统三阳六府诸证，非专论外格。经脉篇以人迎察手足三阳诸病，至三倍而止，为阳气未出三阳本位，固非外格。必至四倍以上，为阳气扬溢于外，离出三阳本位，不与阴气相荣，为阴阳离决之证，方为外格。故禁服篇、终始篇、六节藏象论，俱以人迎四倍以上，论关格之证。禁服篇曰：人迎大一倍于寸口，病在足少阳，一倍而躁，（躁者，一倍之中，而有更躁之意。《素问》云：其有躁者在手。下同。）病在手少阳。人迎二倍，病在足太阳。二倍而躁，病在手太阳。人迎三倍，病在足阳明。三倍而躁，病在手阳明。盛则为热，虚则为寒。又曰：人迎四倍者，且大且数，名曰溢阳。溢阳为外格，死不治。终始篇曰：人迎一盛，病在足少阳。一盛而躁，病在手少阳。人迎二盛，病在足太阳。二盛而躁，病在手太阳。人迎三盛，病在足阳明。三盛而躁，病在手阳明。人迎四盛，且大且数，名曰溢阳。溢阳为外格。六节藏象论曰：十一藏取决于胆，故人迎一盛，病在少阳，二盛病在太阳，三盛病在阳明，四盛以上为格阳。按：此三篇，所指有异。如禁服篇，以一倍二倍三倍察手足三阳诸证，以阳气未出三阳本位，以四位为外格，以阳气离出三阳本位，故曰死不治。终始篇、六节藏象论，不论六府诸病，直以一盛二盛三盛四盛以上论格阳，盖所重在格阳，故不论六府诸病。然六节藏象论，加一故字，以发明诸篇精义。言人迎一盛，所以病在少阳者，十一藏取决于胆故也。以阳明胃脉与太阴肺脉较察者，盖胃为肺脉之根，肺为胃脉之干。五藏别论曰：胃者，水谷之海，六府之大源也。五味入口，藏于胃，以养五藏气，气口亦太阴也。五藏六府之气味，皆出于胃，变见于气口。玉机真藏论曰：五藏者，皆禀气于胃。胃者，五藏之本也。藏气者，不能自致于手太阴，必因于胃气，乃致于手太阴也。盖诊脉之道，必先明岁气，（如春弦、夏洪、秋浮、冬沉、之类。）然后察胃气，然后察藏气，然后察病气。以胃为肺脉之根，肺为胃脉之干，由胃以输脾，由脾以归肺。然五藏六府之气味，皆出于胃，变见于气口。胃虽为脉之根，而变见于气口，则气口乃为要会之地，故可统察十二经之证。扁鹊欲独取寸口，又虑人迎为肺脉之根，《内经》以人迎四倍于寸口为外格证。若不诊人迎，则外格从何较察。深观经旨，推终始、禁服二篇之义，而演之于三难曰：脉有太过，有不及，有阴阳相乘，有覆有溢，有关有格，何谓也？然。关之前者，阳之动也。脉当九分而浮，过者法曰太过，减者法曰不及。遂上鱼为溢，为外关内格，此阴乘之脉也。（乘，凌也。阴乘，即阴凌阳散，无复相荣，乃乖离绝决之象，外关闭而内格绝也。）此上鱼为溢，即终始、禁服二篇所谓人迎四倍，且大且数，名曰溢阳，溢阳为外格之义。（溢阳为外格证之脉，外格为溢阳脉之证。）扁鹊既独取寸口，不诊人迎，推溢阳为外格之意，溢阳为阳气扬溢于外，不与阴气相荣，而关阴于内，使不得出，则阴气内覆，而格阳于外，使不得入，为阴乘阳散，阳气孤悬格绝于外，阴阳相背，无复相荣，故曰外关内格，此阴乘之脉也。阳气扬溢于外，人迎脉大四倍于寸口，则寸口脉小四倍于人迎。今不诊人迎，独取寸口，何以较人迎寸口之大小。盖非以寸口名人迎，以寸口之上察人迎。人迎为寸口肺脉之根，寸口为人迎胃脉之干。人迎脉大至四倍以上，未有不变见于气口者，以根大而干亦大，则以寸口之上察人迎脉也。若经脉、终始、禁服、六节藏象等篇，所谓一倍二倍三倍，（即以喉两旁之人迎。）则寸口之上，亦渐大至一盛二盛三盛。如人迎四倍以上为外格证，则寸口之上亦溢于鱼上为溢阳脉，以应人迎之气，为其根干相通，是寸口以上可察人迎之气，而结喉两旁之人迎，亦不必诊也。此扁鹊独取寸口，以尺寸而分关格覆溢证脉，不诊人迎本意也。仲景因《内经》以人迎胃脉大四倍于寸口肺脉，论格阳证，扁鹊不诊人迎，独取寸口，推《内经》溢阳为外格之意，以寸口之上察人迎，以溢为脉，格为证。然又云：脉有关有格。又云：是皆真藏之脉，人不病而死也。此又似只论脉而不论证，恐后人误认关格为脉体，非证名。（盖脉有关有格者，以脉至四倍以上为关格证之脉也。人不病而死，甚言其证之危。虽不病而人必死，既有其脉，必有其证，故仲景云然。）亦本《内经》溢阳为外格之旨，而明外格证之状。曰脉浮而大，浮为虚，大为实，在寸为格，格则吐逆。脉浮而大，即四倍之类。浮为虚，真气虚。大为实，邪气实。在寸为格，以寸口之上，脉越于鱼际，溢于鱼上，以应人迎之脉，吐逆食不得入，以阳气扬溢于外，胃中全失冲和，安能腐化水谷，是必格拒，吐逆食不得入，故名曰格。（终始篇、禁服篇，名外格。六节藏象论，名格阳。脉度篇，名格。扁鹊、长沙，亦名格。马仲化、张景岳，误以格为脉体，非证名，反笑长沙以格误作《内经》之膈证，盖不知格乃膈之终也。）乃膈食之终也。仲景犹恐以浮大为关格，而仍误认关格为脉体，复详于趺阳脉曰：趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名曰关格。（按：关格可分可合，格阳亦可名关格，关阴亦可名关格，不过以内外之分。终始篇、禁服篇，俱以人迎四倍且大且数，名曰溢阳。溢阳为外格。扁鹊外关内格之意本此。又论格阳证，亦以关格称之。故长沙详趺阳脉论格阳证，名曰关格。）盖趺阳即足阳明胃脉之在足者。（按：《伤寒论》自序云：按寸不及尺，握手不及足，人迎趺阳三部不参，即人迎在喉为上部，趺阳在足为下部，举其上下，则寸口在其中矣，为中部。足见人迎不在左手。）趺阳脉伏涩，为胃气不通于下，而扬溢于上。故人迎脉大四倍以上，上之人迎脉大为关格，下之趺阳脉伏涩亦为关格，则关格为证明矣。而后世犹然不解，皆惑于《脉经》《脉诀》，妄指左手为人迎，右手为气口，及马仲化谬谓扁鹊、长沙以尺寸分关格为误，指关格为脉体，非证名等说也。马仲化曰：按《伤寒论》云：寸口脉浮而大，浮为虚，大为实，在寸为格，格则吐逆，趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名曰关格。夫《内经》诸篇，分明以左手人迎（按《内经》无左手为人迎之文。）脉大，自一盛以至四盛，乃手足六阳经为病，其名曰格。故春夏人迎微大者为无病。今仲景曰：在寸为格。又曰：格则吐逆。是以格脉误为内经之膈证。《此事难知》集、李东垣宗之。且曰：气口之脉，大四倍于人迎，则又同于《难经》三十七难之误。按：三十七难，本《灵枢》脉度篇，推明关格为证，以申三难之义。马氏不知关格为证，误以为脉，故言之颠倒如此。据马氏此论，以左手为人迎，关格为脉体，故不得不以扁鹊、长沙为误。左手为人迎，则尺寸不能分关格。（在尺为关，在寸为格。若以左为人迎论格，则右为气口论关，与尺无涉。盖不知寸口以上察人迎，尺中以下察气口，无分左右也。）关格为脉体，则吐逆食不得入，不能为格证。盖不知《内经》本以关格为证名，故扁鹊恐后人误认关格为脉体，推覆溢脉之名。（脉有名，则关格是证，上鱼为溢，入尺为覆。）长沙亦恐后人误认关格为脉体，明关格证之状。（证有状、则关格非脉，关则不得小便，格则吐逆，）而马氏犹然不悟，反以为非。且曰《内经》诸篇，分明以左手为人迎。今偏考《内经》，并无左手为人迎之说，（吴鹤皋亦曰：此家脉法法象，阳左阴右，自为一家，左手关上为人迎，此盖思之而未得其解，遂曰自为一家。殊属可笑。）皆为《脉经》《脉诀》所误，且曲为之解，何其谬信如此。张景岳曰：人迎，足阳明胃脉也，在颈下夹结喉旁一寸五分。一盛二盛，犹言一倍二倍，谓以人迎寸口相较，或此大于彼，或彼大于此，而有三倍四倍之殊也。禁服篇曰：寸口主中，人迎主外，两者相应，俱往俱来，若引绳大小齐等。春夏人迎微大，秋冬寸口微大，如是者，命曰平人。故人迎寸口而至于盛衰相倍者，乃不免于病矣。然人迎候阳，故一盛在少阳胆与三焦也。二盛在太阳膀胱小肠也。三盛在阳明胃与大肠也。四盛以上者，以阳脉盛极，而阴无以通，故曰格阳。又曰：愚按关格脉证，本经垂训极明，世人病此不少，而历代医师每各立名目，以相传训，甚至并其大义而失之。其谬甚矣。夫所谓关格者，阴阳否绝不相荣运，乖羸离败之候也。故人迎故盛者，病在三阳之府也。阳明行气于三阳，而人迎之脉，在结喉之旁也。故古法诊三阳之气于人迎，如四时气篇曰：人迎候阳，正谓此也。又曰：又按关格之脉，如六节藏象、脉度、终始、禁服、经脉等篇，言之再四，盖恐其难明，故宣而又宣，诚重之也。而后世诸贤，鲜有得其旨者，岂皆未之察耶。夫人迎在颈，系阳明表脉，故人迎倍大者曰格阳。此以阴阳否绝，气不相营，故名关格，不可易也。而三难曰：脉有太过，有不及，有阴阳相乘，有覆有溢，有关有格，何谓也？然。关之前者，阳之动也。脉当九分而浮，过者法曰太过，减者法曰不及，遂上鱼为溢，为外关内格，此阴乘之脉也。故仲景宗之曰：在寸为格，格则吐厥。夫人迎四倍，既非寸口之谓，（寸口以上察人迎，故曰在寸为格。景岳盖未知此。）而曰吐厥者，即膈食一证耳。（景岳不知膈食，进而为关格。）此证未必至死，何《内经》谆谆特重之若是耶。继自叔和以后，俱莫能辨，悉以尺寸言关格，（景岳盖不知寸口以上察人迎，尺脉以下察寸口。）而且云左为人格，以致后世惑乱，遂并阴阳表里大义，尽皆失之。迨及东垣之宗《脉经》者，则亦以左为人迎，曰气口之脉，大四倍于人迎，此清气反行浊道也。故曰格。（气口之脉大四倍于人迎，即寸口以上渐大至四倍，以应喉旁之人迎，已将达《内经》扁鹊长沙之旨，而不舍左为人迎谬说，此东垣将悟未悟，为《脉经》《脉诀》所误，遂不能悟。惜哉！）甚至丹溪特立关格一门，曰此证多死，寒在上，热在下，脉两寸俱盛四倍以上。夫两寸俱盛四倍，又安得为寒在上，热在下耶。其说愈乖，其义愈失，致使后学茫然莫知所辨。欲求无误，其可得乎。独近代马玄台知诸子之非，谓关格之义，非膈食闭癃之证，（癃闭，乃津液不通，一时阻塞而闭。关则不得小便，乃津液枯涸而闭。膈食乃关格之始，马仲化盖未知此。）曰：呜呼痛哉！轩歧之旨乎。秦张王李朱，后世业医者所宗，尚与《内经》渺然如此，况能使后世下工，复知关格为脉体，而非病名也。又焉能决关格脉之死生，治关格脉之病证，及治膈证闭癃证而无谬也哉。此马子之言诚是也。然观其诸篇之注，则亦未详经义，谬宗叔和，仍以左为人迎，竟置阳明胃脉于乌有，而仍失本经表里阴阳，根本对待之义，此其复为误也。据张氏此论，谓人迎在结喉两旁，诚过人之见，然不知两寸之上察人迎，而私淑玄台之谬说，故反以扁鹊、长沙为误，致令关格证脉不分。如曰愚按关格脉证，又曰又按关格之脉，则关格曰证可也。曰脉可也。（关格为覆溢脉之证，覆溢为关格证之脉。）若以关格为证，不应指丹溪为非，亦当悟仲景明关格证状之意。若以关格为脉，不合《内经》本旨，亦当悟扁鹊推覆溢脉名之意。此景岳不敢背经义，而惑于仲化谬论，不达扁鹊、长沙之旨，以故议论多歧。且言如六节藏象、脉度、终始、禁服、经脉等篇，言之再四，盖恐其难明，故宣而又宣，亦不言《内经》所以宣人格在喉旁之义。自矜其辨，执人迎在结喉两旁，以证诸家之误，而不达扁鹊以寸口之上论格阳，推格阳脉名，以上鱼为溢，为格阳证之脉名。长沙以寸口之上论格阳，明格阳证状。以吐逆食不得入，为格阳证之证状，反以为非是，脉体明而证又晦，证既晦则脉亦不明，证脉不符于理则悖，反使人迎复晦，可为痛惜。
这位患者的“人迎”脉位于喉结两侧，而不是在左手，这是第五个证据。
另外，《黄帝内经·阴阳类论》中提到，黄帝认为三阳经的脉气会到达手太阴肺经。又说：“一阳”指的是少阳经。少阳经的气血上行连接至人迎。这就是在寸口（手腕桡动脉处）以上观察人迎脉的方法，也就是所谓的人迎与寸口上下相互呼应的诊法。如果把左手当作人迎，那么“上”这个方位词就没有着落了。如果把左手的寸部之上当作人迎，那么“手太阴经向上连接人迎”这句话又该作何解释呢？手太阴经对应的就是寸口脉。既然已经设定左手为人迎，右手为寸口，那么在寸口之上如果还有人迎，就意味着人迎位于右寸之上，这就更不能说左手是人迎了。
此外，《黄帝内经·平人气象论》中说：“颈部脉搏跳动急促并伴有气喘咳嗽的，是水气病。”颈部的脉动指的就是人迎脉。人迎脉位于喉结两旁，不在左手，这是第五个证据。
另外，《周礼》中医师郑玄（字康成）注释说：脉象的主要征候，关键在于阳明经的寸口。贾公彦疏解说：阳明经，位于大拇指根部高骨的最高处，以及第二指之间。寸口，位于大拇指根部高骨后方一寸的地方。
按：郑玄的注释指出，脉象的主要征候在于阳明经的寸口。这里的“阳明”即胃经的人迎脉，“寸口”即肺经的脉象。因为这两条脉是全身百脉的根源，所以被视为关键。贾公彦的疏解说，阳明经位于大拇指根部高骨最高处和第二指之间，这实际上是阳明经所属部位的脉象，即《素问·脉要精微论》中提到的“右侧外侧以候胃”的部位。阳明经属胃，位于右关脉的外侧，所以靠近第二指间，但这并非阳明经的本部。阳明经的本部，就是人迎脉，位于喉结两旁。寸口位于大拇指根部高骨后方一寸，这是尺中部位，也就是扁鹊和长沙（张仲景）所说的在两手尺部之下察寸口脉的意思。大拇指根部的高骨是关脉的位置。贾公彦只知道在尺部之下察寸口，却不知道在寸部之上察人迎，因此错误地认为阳明经本部在右关脉的外侧，这也是人迎脉不在左手的又一证据。
《内经》原本用人迎脉来统领三阳经和六腑的各种病证，并不是专门论述外格证。《经脉篇》通过人迎脉来观察手足三阳经的各种疾病，脉大至三倍为止，这说明阳气尚未超出三阳经的本位，确实不是外格证。必须达到四倍以上，才是阳气扬溢于体外，离开了三阳经的本位，不与阴气相协调，属于阴阳离决的病证，这才称为外格。因此，《禁服篇》、《终始篇》、《六节藏象论》都用人迎脉大四倍以上的情况，来论述关格证。
《禁服篇》说：人迎脉比寸口大一倍，病在足少阳经；如果在一倍的基础上兼见躁动之象，病在手少阳经。（躁动之意，是指在一倍之中，有更躁动的含义。《素问》说：有躁动表现的在手经。以下同。）人迎脉大二倍，病在足太阳经；二倍兼躁，病在手太阳经。人迎脉大三倍，病在足阳明经；三倍兼躁，病在手阳明经。脉盛则为热，脉虚则为寒。又说：人迎脉大四倍的，既大又快，称为“溢阳”。溢阳即为外格，预后不良，难以治愈。
《终始篇》说：人迎脉大一倍（一盛），病在足少阳经；一倍兼躁，病在手少阳经。人迎脉大二倍（二盛），病在足太阳经；二倍兼躁，病在手太阳经。人迎脉大三倍（三盛），病在足阳明经；三倍兼躁，病在手阳明经。人迎脉大四倍（四盛），既大又快，称为“溢阳”。溢阳即为外格。
《六节藏象论》说：十一脏的功能取决于胆，所以人迎脉大一倍，病在少阳经；二倍病在太阳经；三倍病在阳明经；四倍以上为格阳证。
按：这三篇文献所指有所不同。如《禁服篇》，用一倍、二倍、三倍来观察手足三阳经的各种病证，认为阳气未出三阳本位；以四倍为外格，认为阳气已离开三阳本位，所以说“死不治”。《终始篇》和《六节藏象论》不讨论六腑的各种病证，直接以一盛、二盛、三盛、四盛以上来论述格阳证，大概是因为重点在于格阳证，所以不讨论其他六腑病证。然而，《六节藏象论》加了一个“故”字，是为了阐明各篇的精义。它说人迎大一倍之所以病在少阳经，是因为“十一脏取决于胆”的缘故。
之所以比较阳明胃脉和太阴肺脉，是因为胃是肺脉的根，肺是胃脉的干（主干）。《五藏别论》说：胃是水谷之海，六腑的大源头。五味入口，储藏于胃，用来滋养五脏之气，气口（寸口）也属于太阴经。五脏六腑的气味，都出于胃，变化显现于气口。《玉机真藏论》说：五脏都禀受于胃气。胃是五脏的根本。脏气不能自己到达手太阴肺经，必须依赖胃气，才能到达手太阴肺经。
大概诊脉的道理，必须先明了岁气（如春弦、夏洪、秋浮、冬沉等），然后察胃气，再察脏气，最后察病气。因为胃是肺脉的根，肺是胃脉的干，由胃输送给脾，由脾归并于肺。然而五脏六腑的气味都出于胃，变化显现于气口。胃虽然是脉的根，但变化显现于气口，所以气口是重要的汇聚之地，因此可以统察十二经的病证。
扁鹊想要独取寸口脉，但又担心人迎作为肺脉之根的重要性，《内经》以人迎脉大四倍于寸口作为外格证。如果不诊人迎，那么外格证从何比较观察呢？深入探究经旨，推究《终始篇》、《禁服篇》的含义，并在《难经·三难》中演绎道：脉有太过，有不及，有阴阳相乘，有覆有溢，有关有格，这是什么意思呢？回答说：关之前方，是阳气的变动处。脉应当在九分深处而浮起，超过这个限度叫太过，不足这个限度叫不及。于是脉气上达鱼际称为“溢”，形成外关内格，这是阴气凌乘阳气的脉象。（乘，意为欺凌。阴乘，即阴气欺凌阳气散乱，不再相互协调，是乖离绝决的现象，外部关闭而内部格拒。）这种上达鱼际为溢的脉象，就是《终始篇》、《禁服篇》所说的人迎脉大四倍，既大又快，称为溢阳，溢阳即为外格的含义。（溢阳是外格证的脉象，外格是溢阳脉所主的病证。）
扁鹊既然独取寸口，不诊人迎，推演溢阳为外格的意思：溢阳是阳气扬溢于外，不与阴气协调，而在内部关闭阴气，使其不得外出；这样阴气在内覆盖，格拒阳气于外，使其不得入内，导致阴乘阳散，阳气孤悬格绝于外，阴阳背离，不再相互协调，所以称为“外关内格”，这是阴乘的脉象。阳气扬溢于外，人迎脉大四倍于寸口，那么寸口脉就小四倍于人迎。现在不诊人迎，只取寸口，凭什么比较人迎和寸口的大小呢？这并不是把寸口叫做人迎，也不是在寸口之上察人迎。人迎是寸口肺脉的根，寸口是人迎胃脉的干。人迎脉大到四倍以上，没有不在气口有所变化的，因为根大则干也大，所以可以通过寸口以上来察知人迎脉的情况。
如果像《经脉篇》、《终始篇》、《禁服篇》、《六节藏象论》等篇所说的一倍、二倍、三倍（即指喉旁两侧的人迎脉），那么寸口以上也会逐渐增大至一盛、二盛、三盛。如果人迎脉大四倍以上为外格证，那么寸口以上也会溢出鱼际成为溢阳脉，以应和人迎之气，因为根和干是相通的。所以在寸口以上可以察知人迎之气，而喉结两旁的人迎脉，也不必专门去诊察了。这就是扁鹊独取寸口，以尺寸分部来区分关格、覆溢证脉，而不诊人迎的本意。
张仲景依据《内经》中人迎胃脉大四倍于寸口肺脉来论述格阳证。扁鹊不诊人迎，独取寸口，推演《内经》溢阳为外格的意思，以寸口以上察人迎，以“溢”为脉名，“格”为证名。但是他又说：脉有关有格。又说：这些都是真脏脉，人虽无病也会死亡。这又似乎只论脉而不论证，恐怕后人误认关格为脉体名称，而非病证名称。（大概脉有关有格，是指脉至四倍以上为关格证的脉象。人不病而死，是极言其病证的危重。虽然表面不病但人必死，既有其脉，必有其证，所以仲景这样说。）这也本于《内经》溢阳为外格的宗旨，而阐明外格证的症状。他说：脉浮而大，浮表示虚，大表示实，出现在寸部为格，格则呕吐逆气。脉浮而大，就是大四倍之类。浮为虚，真气虚；大为实，邪气实。在寸部为格，是因为在寸口以上，脉越过了鱼际，溢出鱼际，以应和人迎的脉象；呕吐逆气，食物无法进入，是因为阳气扬溢于外，胃中完全失去了冲和之气，怎么能腐熟消化水谷呢？这必然会导致格拒，呕吐逆气，食物无法进入，所以名叫“格”。（《终始篇》、《禁服篇》称为外格；《六节藏象论》称为格阳；《脉度篇》称为格；扁鹊、张仲景也称为格；马仲化、张景岳错误地把格当作脉体名称，而非证名，反而嘲笑张仲景把格误作《内经》中的膈证，大概不知道格是膈的终末阶段。）这是膈食证的终末阶段。
张仲景仍然担心人们把浮大脉误认为是关格，从而继续误认关格为脉体，又在趺阳脉上详细说明：趺阳脉伏而涩，伏则呕吐逆气，水谷不化；涩则食物无法进入，名叫关格。（按：关格可以分开也可以合称，格阳也可以叫关格，关阴也可以叫关格，不过是以内外来区分。《终始篇》、《禁服篇》都以人迎脉大四倍且大又快，称为溢阳，溢阳为外格。扁鹊外关内格的意思本于此。又论述格阳证时，也以关格称呼它。所以张仲景详细论述趺阳脉来论证格阳证，命名为关格。）大概趺阳脉就是足阳明胃脉在足部的表现。（按：《伤寒论》自序说：按寸不及尺，握手不及足，人迎、趺阳三部不参合，即人迎在喉为上部，趺阳在足为下部，举其上下，则寸口在其中了，为中部。可见人迎不在左手。）趺阳脉伏涩，表示胃气不通于下，而扬溢于上。所以人迎脉大四倍以上，上部的人迎脉大为关格，下部的趺阳脉伏涩也为关格，那么关格作为病证就明确了。
然而后世仍然不理解，都被《脉经》、《脉诀》迷惑，妄指左手为人迎，右手为气口，以及马仲化错误地认为扁鹊、张仲景以尺寸区分关格是错误的，指关格为脉体名称，非病证名称等说法。
马仲化说：按《伤寒论》说：寸口脉浮而大，浮为虚，大为实，在寸部为格，格则吐逆；趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名叫关格。夫《内经》诸篇，分明以左手人迎脉大，自一盛以至四盛，乃手足六阳经为病，其名曰格。所以春夏季节人迎脉微大的是无病之人。现在仲景说：在寸部为格。又说：格则吐逆。这是把格脉误认为是《内经》中的膈证。《此事难知》集和李东垣都宗奉这一观点。并且说：气口脉大四倍于人迎，那就又同于《难经》第三十七难的错误了。
按：第三十七难，本于《灵枢·脉度篇》，推明关格为病证，以申述第三难的含义。马氏不知道关格是病证，误以为是脉象，所以说得颠三倒四。根据马氏的这种理论，以左手为人迎，关格为脉体，所以不得不认为扁鹊、张仲景是错误的。如果以左手为人迎，那么寸部和尺部就不能区分关格了。（在尺部为关，在寸部为格。如果以左手为人迎来论述格，那么右手为气口来论述关，就和尺部无关了。大概是不懂在寸口以上察人迎，尺中以下察气口，不分左右的原因。）如果关格是脉体，那么呕吐逆气、食物不得入内，就不能作为格证了。大概是不懂《内经》本来就把关格作为病证名称，所以扁鹊担心后人误认关格为脉体，推演覆溢脉的名称。（脉有名称，则关格是证，上鱼际为溢，入尺部为覆。）张仲景也担心后人误认关格为脉体，阐明关格证的症状。（证有症状，则关格不是脉，关则不得小便，格则吐逆。）而马氏仍然不觉悟，反而认为不对。并且说《内经》诸篇，分明以左手为人迎。现在专门考证《内经》，并没有左手为人迎的说法，（吴鹤皋也说：这是家传脉法的法象，阳左阴右，自成一家，左手关上为人迎，这大概是思考而未得其解，就说自成一家。实在可笑。）都是被《脉经》、《脉诀》所误导，并且曲意为之辩解，为何如此谬信呢？
张景岳说：人迎，是足阳明胃脉，位于颈部下方夹结喉旁一寸五分。一盛二盛，犹言一倍二倍，谓以人迎、寸口相比较，或者此大于彼，或者彼大于此，而有三倍四倍的不同。《禁服篇》说：寸口主内（里），人迎主外（表），两者相应，俱往俱来，像拉绳子一样大小相等。春夏人迎微大，秋冬寸口微大，像这样的人，叫做平人（健康人）。所以人迎、寸口至于盛衰相倍者，就不免生病了。然而人迎候阳气，所以一盛在少阳胆与三焦经。二盛在太阳膀胱与小肠经。三盛在阳明胃与大肠经。四盛以上的，因为阳脉盛极，而阴气无法通达，所以叫格阳。
又说：我按：关格脉证，本经垂训极为明确，世人患此病不少，而历代医师各自立名目，相传训，甚至连大义都丢失了。这谬误太严重了。所谓关格，是阴阳否绝不相协调运行，乖离败坏的症状。所以人迎脉盛的，病在三阳之腑。阳明经行气于三阳，而人迎脉在结喉之旁。所以古法在人迎诊察三阳之气，如《四时气篇》说：人迎候阳，正是说的这个意思。
又说：我又按：关格的脉，如《六节藏象论》、《脉度篇》、《终始篇》、《禁服篇》、《经脉篇》等篇，反复说了多次，大概是怕它难以明白，所以宣示而又宣示，确实很重视它。而后世各位贤人，很少能得其旨意的，难道都是没有考察吗？
夫人迎在颈部，属于阳明表脉，所以人迎脉倍大的叫格阳。这是因为阴阳否绝，气不相营，所以名叫关格，不可改变。而《难经·三难》说：脉有太过，有不及，有阴阳相乘，有覆有溢，有关有格，是什么意思呢？回答说：关之前方，是阳气的变动处。脉应当在九分深处而浮起，超过这个限度叫太过，不足这个限度叫不及，于是上达鱼际为溢，为外关内格，这是阴乘的脉象。所以仲景宗奉它说：在寸部为格，格则吐厥。
夫人迎大四倍，既然不是指寸口（因为是在寸口以上察人迎，所以说在寸部为格。张景岳大概不知道这一点），而说吐厥的，就是膈食一证罢了。（张景岳不知道膈食进而发展为关格。）这个病证未必致死，为什么《内经》如此谆谆告诫特别重视它呢？
自从王叔和以后，都不能辨别，全都以尺寸来言关格，（张景岳大概不知道寸口以上察人迎，尺脉以下察寸口。）而且说左为人格，以致后世惑乱，于是连阴阳表里的大义都全部丢失了。等到李东垣宗奉《脉经》的人，则以左手为人迎，说气口脉大四倍于人迎，这是清气反行浊道。所以叫格。（气口脉大四倍于人迎，即寸口以上逐渐增大至四倍，以应和喉旁的人迎，这已经接近《内经》、扁鹊、张仲景的宗旨，但不舍弃左手为人迎的谬说，这是李东垣将悟未悟，被《脉经》、《脉诀》所误，所以不能醒悟。可惜啊！）甚至朱丹溪特立关格一门，说此证多死，寒在上，热在下，脉两寸俱盛四倍以上。夫两寸俱盛四倍，又怎么说是寒在上，热在下呢？他的说法越来越违背常理，意义越来越丢失，致使后学茫然不知如何辨别。想要寻求无误，怎么可能呢？
唯独近代的马玄台知道诸子的错误，认为关格的含义，不是膈食闭癃的证候，（癃闭，是津液不通，一时阻塞而闭。关则是不得小便，是津液枯涸而闭。膈食是关格的开始，马仲化大概不知道这一点。）说：呜呼痛哉！这是违背了轩辕岐伯的宗旨啊！秦汉以来的张仲景、王叔和、李东垣、朱震亨，是后世业医者所宗奉的，尚且与《内经》相差如此遥远，何况能使后世低水平的医生，重新知道关格是脉体，而非病名呢？又怎么能判断关格脉的死生，治疗关格脉的病证，以及治疗膈证、闭癃证而没有谬误呢？马先生的话确实是正确的。
然而看他的诸篇注释，也没有详明经义，错误地宗奉王叔和，仍以左手为人迎，竟然置阳明胃脉于不存在，而仍然丢失了本经表里阴阳、根本对待的意义，这是他再次陷入错误。
根据张景岳的这段论述，谓人迎在结喉两旁，确实是过人的见解，但他不知道在两寸之上察人迎，而私下信奉马玄台的谬说，所以反而认为扁鹊、张仲景是错误的，致使关格证脉不分。如果说“我按：关格脉证”，又说“我又按：关格之脉”，那么说关格是证也可以，说关格是脉也可以。（关格是覆溢脉的病证，覆溢是关格证的脉象。）如果以关格为证，不应该指责朱丹溪为非，也应该领悟张仲景阐明关格证状的意思。如果以关格为脉，不合《内经》本旨，也应该领悟扁鹊推演覆溢脉名的意思。
张景岳不敢违背经义，却迷惑于马仲化的谬论，不达扁鹊、张仲景的宗旨，所以议论多有分歧。并且说如《六节藏象论》、《脉度篇》、《终始篇》、《禁服篇》、《经脉篇》等篇，反复说了多次，大概是怕它难以明白，所以宣示而又宣示，也不说《内经》所以宣扬人格在喉旁的意义。自夸其辨析，执着于人迎在结喉两旁，以证明诸家的错误，却不达扁鹊以寸口以上论述格阳，推演格阳脉名，以上鱼际为溢，作为格阳证的脉名；张仲景以寸口以上论述格阳，阐明格阳证状，以呕吐逆气、食物不得入内，作为格阳证的证状，反而认为不对，脉体明确了而病证又晦暗，病证既晦暗则脉也不明确，证脉不符于理则悖谬，反而使人迎脉更加晦暗，真是令人痛惜。
The "Renying" (Human Welcome) pulse of this patient is located on both sides of the laryngeal prominence, not on the left hand; this is the fifth piece of evidence.
Furthermore, in the *Yin Yang Lei Lun* (Treatise on Yin and Yang Categories) of the *Huangdi Neijing* (Yellow Emperor's Inner Canon), it is stated that the pulses of the Three Yang meridians reach the Lung Meridian of Hand-Taiyin. It also says: "One Yang" refers to the Shaoyang (Lesser Yang) meridian. The Qi of the Shaoyang meridian ascends and connects to the Renying. This refers to observing the Renying pulse above the Cunkou (Inlet/Market) pulse at the wrist, which is what is meant by the mutual correspondence between the Renying and Cunkou pulses above and below. If the left hand were considered the Renying, the term "above" would have no reference point. If the area above the Cun position on the left hand were considered the Renying, how would one explain the statement that the "Lung Meridian of Hand-Taiyin connects upward to the Renying"? The Lung Meridian of Hand-Taiyin corresponds to the Cunkou pulse. Since it has already been established that the left hand is Renying and the right hand is Cunkou, if there is a Renying above the Cunkou, it implies the Renying is above the Right Cun position, making it impossible to claim the left hand is the Renying.
Additionally, the *Ping Ren Qi Xiang Lun* (Treatise on the Pulse Phenomena of Healthy Persons) states: "Pulsation of the neck vessels accompanied by panting and rapid cough indicates Water Disease." The pulsation of the neck vessels refers to the Renying pulse. The Renying pulse is located on both sides of the laryngeal prominence, not on the left hand; this constitutes the fifth piece of evidence.
Moreover, in the commentary by Zheng Xuan (courtesy name Kangcheng) on the Physicians section of the *Zhou Li* (Rites of Zhou), it is noted: "The major indicators of the pulse lie primarily in the Yangming Cunkou." Jia Gongyan's sub-commentary explains: "Yangming is located at the highest point of the proximal phalanx bone of the thumb and between the first and second fingers. The Cunkou is located one cun behind the highest point of the proximal phalanx bone of the thumb."
Analysis: Zheng Xuan’s note states that the major indicators of the pulse lie in the Yangming Cunkou. Here, "Yangming" refers to the Renying pulse of the Stomach meridian, and "Cunkou" refers to the pulse of the Lung meridian. Because these two pulses are the roots of all hundred vessels, they are considered crucial. Jia Gongyan’s sub-commentary states that Yangming is located at the highest point of the proximal phalanx bone of the thumb and between the first and second fingers; this actually refers to the pulse in the region belonging to the Yangming meridian, specifically the area described in *Suwen: Mai Yao Jing Wei Lun* (Essential Meanings of Pulse Investigation) as "the lateral side of the right hand to observe the Stomach." The Yangming meridian belongs to the Stomach and is located laterally to the Guan position on the right wrist, hence close to the space between the first and second fingers, but this is not the main body of the Yangming meridian. The main body of the Yangming meridian is the Renying pulse, located on both sides of the laryngeal prominence. The Cunkou is located one cun behind the highest point of the proximal phalanx bone of the thumb, which corresponds to the Chi (Cubit) position. This aligns with the intent of Bian Que and Changsha (Zhang Zhongjing) to observe the Cunkou pulse below the Chi positions. The highest point of the proximal phalanx bone of the thumb is the Guan (Barrier) position. Jia Gongyan only knew to observe the Cunkou below the Chi positions but did not know to observe the Renying above the Cun positions, thus erroneously concluding that the main body of the Yangming meridian is on the lateral side of the Right Guan position. This is another piece of evidence that the Renying is not on the left hand.
The *Neijing* originally used the Renying pulse to govern the syndromes of the Three Yang meridians and the Six Fu organs, not specifically to discuss Wai Ge (External Grid). In the *Jing Mai Pian* (Treatise on the Meridians), the Renying pulse is used to observe diseases of the Hand and Foot Three Yang meridians; a pulse magnitude up to three times normal indicates that Yang Qi has not yet exited its original position within the Three Yang meridians, and thus is indeed not Wai Ge. Only when the pulse reaches four times or more does it indicate that Yang Qi is overflowing externally, leaving the original position of the Three Yang meridians, failing to harmonize with Yin Qi, representing a syndrome of separation and dissolution of Yin and Yang, which is termed Wai Ge. Therefore, the *Jin Fu Pian* (Treatise on Forbidden Treatment), *Zhong Shi Pian* (Treatise on Beginning and End), and *Liu Jie Zang Xiang Lun* (Treatise on the Six Periods and Viscera Manifestations) all use the Renying pulse being four times larger than the Cunkou to discuss the Guan Ge (Internal/External Grid) syndrome.
The *Jin Fu Pian* states: "When the Renying pulse is one times larger than the Cunkou, the disease is in the Foot Shaoyang meridian; if it is one times larger and restless, the disease is in the Hand Shaoyang meridian. ('Restless' implies a sense of agitation within the 'one times' magnitude. As stated in *Suwen*: 'Those with restlessness are in the Hand meridians.' The same applies below.) When the Renying pulse is two times larger, the disease is in the Foot Taiyang meridian; if two times larger and restless, the disease is in the Hand Taiyang meridian. When the Renying pulse is three times larger, the disease is in the Foot Yangming meridian; if three times larger and restless, the disease is in the Hand Yangming meridian. Excess manifests as heat, deficiency manifests as cold." It further states: "When the Renying pulse is four times larger, it is both large and rapid, named Yi Yang (Overflowing Yang). Yi Yang constitutes Wai Ge (External Grid), which is incurable and fatal."
The *Zhong Shi Pian* states: "When the Renying pulse is one excess (Yi Sheng), the disease is in the Foot Shaoyang meridian. One excess and restless, the disease is in the Hand Shaoyang meridian. Two excesses, the disease is in the Foot Taiyang meridian. Two excesses and restless, the disease is in the Hand Taiyang meridian. Three excesses, the disease is in the Foot Yangming meridian. Three excesses and restless, the disease is in the Hand Yangming meridian. Four excesses, it is both large and rapid, named Yi Yang. Yi Yang constitutes Wai Ge."
The *Liu Jie Zang Xiang Lun* states: "The eleven Zang organs depend on the Gallbladder; therefore, when the Renying pulse is one excess, the disease is in Shaoyang; two excesses, in Taiyang; three excesses, in Yangming; four excesses and above constitute Ge Yang (Grid of Yang)."
Analysis: These three chapters refer to different aspects. For instance, the *Jin Fu Pian* uses one, two, and three times to observe various syndromes of the Hand and Foot Three Yang meridians, considering that Yang Qi has not exited the original position of the Three Yang meridians. It considers four times as Wai Ge, indicating that Yang Qi has left the original position of the Three Yang meridians, hence stating it is fatal. The *Zhong Shi Pian* and *Liu Jie Zang Xiang Lun* do not discuss various diseases of the Six Fu organs but directly discuss Ge Yang using one, two, three, and four excesses and above, likely because the focus is on Ge Yang, so other Six Fu organ diseases are not discussed. However, the *Liu Jie Zang Xiang Lun* adds the word "therefore" (Gu) to elucidate the essence of the previous chapters. It states that the reason for disease in Shaoyang when the Renying pulse is one excess is due to the principle that "the eleven Zang organs depend on the Gallbladder."
The comparison between the Yangming Stomach pulse and the Taiyin Lung pulse is made because the Stomach is the root of the Lung pulse, and the Lung is the trunk of the Stomach pulse. The *Wu Zang Bie Lun* (Treatise on the Distinction of the Five Zang Organs) states: "The Stomach is the sea of water and grain, the great source of the Six Fu organs. The five flavors enter the mouth, are stored in the Stomach, and nourish the Qi of the Five Zang organs. The Qi Kou (Cunkou) also belongs to the Taiyin meridian. The Qi and flavor of the Five Zang and Six Fu organs all originate from the Stomach and manifest in the Qi Kou." The *Yu Ji Zhen Zang Lun* (Treatise on the True Viscera Pulses of the Jade Machine) states: "The Five Zang organs all receive Qi from the Stomach. The Stomach is the root of the Five Zang organs. The Qi of the Zang organs cannot reach the Hand-Taiyin Lung meridian on its own; it must rely on Stomach Qi to reach the Hand-Taiyin."
Generally, the method of pulse diagnosis requires first understanding the Annual Qi (e.g., Spring stringy, Summer surging, Autumn floating, Winter deep), then observing Stomach Qi, then Zang Qi, and finally Pathogenic Qi. Since the Stomach is the root of the Lung pulse and the Lung is the trunk of the Stomach pulse, Qi flows from the Stomach to the Spleen, and from the Spleen back to the Lung. However, since the Qi and flavor of the Five Zang and Six Fu organs all originate from the Stomach and manifest in the Qi Kou, although the Stomach is the root of the pulse, its manifestation occurs at the Qi Kou. Thus, the Qi Kou is the critical convergence point and can be used to comprehensively observe syndromes of the Twelve Meridians.
Bian Que wished to take only the Cunkou pulse but was concerned about the importance of the Renying as the root of the Lung pulse. The *Neijing* uses the Renying pulse being four times larger than the Cunkou as the sign of Wai Ge. If the Renying is not diagnosed, how can Wai Ge be compared and observed? Deeply studying the canonical principles and deducing the meanings of the *Zhong Shi Pian* and *Jin Fu Pian*, the *Nan Jing* (Classic of Difficult Issues) Third Difficulty elaborates: "Pulses may be excessive, deficient, involve Yin overcoming Yang, be inverted (Fu), overflow (Yi), be closed (Guan), or gridlocked (Ge). What does this mean?" The response is: "Anterior to the Guan position is the movement of Yang. The pulse should be nine fen deep and floating. Exceeding this is termed Excessive; falling short is termed Deficient. If it rises to the Yuji (Fish Border) acupoint, it is called Overflow (Yi), forming External Closure and Internal Grid (Wai Guan Nei Ge); this is a pulse of Yin overcoming Yang. (Overcoming means bullying. Yin overcoming means Yin bullies and scatters Yang, ceasing to harmonize, representing a state of alienation and severance, where the exterior closes and the interior grids.) This rising to the Fish Border as Overflow is the meaning referred to in the *Zhong Shi Pian* and *Jin Fu Pian* as the Renying pulse being four times larger, both large and rapid, named Yi Yang, where Yi Yang constitutes Wai Ge. (Yi Yang is the pulse of the Wai Ge syndrome; Wai Ge is the syndrome manifested by the Yi Yang pulse.)"
Since Bian Que took only the Cunkou and did not diagnose the Renying, he deduced the meaning of Yi Yang as Wai Ge: Yi Yang is Yang Qi overflowing externally, not harmonizing with Yin Qi, while closing Yin internally, preventing it from exiting. Consequently, Yin covers internally, gridlocking Yang externally, preventing it from entering, leading to Yin overcoming and scattering Yang, with Yang isolated and severed externally, Yin and Yang opposing each other without harmony, thus termed "External Closure and Internal Grid," which is a pulse of Yin overcoming. When Yang Qi overflows externally, the Renying pulse is four times larger than the Cunkou, meaning the Cunkou pulse is four times smaller than the Renying. Now, without diagnosing the Renying and taking only the Cunkou, how can one compare the size of the Renying and Cunkou? This does not mean naming the Cunkou as Renying, nor does it mean observing the Renying above the Cunkou. The Renying is the root of the Cunkou/Lung pulse, and the Cunkou is the trunk of the Renying/Stomach pulse. When the Renying pulse becomes four times larger or more, it invariably manifests in the Qi Kou, because if the root is large, the trunk is also large. Thus, the Renying pulse can be observed via the area above the Cunkou.
If, as stated in the *Jing Mai Pian*, *Zhong Shi Pian*, *Jin Fu Pian*, and *Liu Jie Zang Xiang Lun*, the magnitudes of one, two, and three times refer to the Renying on both sides of the throat, then the area above the Cunkou will gradually increase to one, two, and three excesses. If the Renying pulse being four times larger constitutes Wai Ge, then the area above the Cunkou will also overflow onto the Fish Border as an Yi Yang pulse, responding to the Qi of the Renying, because the root and trunk are connected. Therefore, the Qi of the Renying can be observed above the Cunkou, and it is unnecessary to diagnose the Renying at the sides of the laryngeal prominence. This is the original intent of Bian Que taking only the Cunkou and distinguishing Guan Ge, Fu, and Yi syndromes/pulses by the Cun and Chi positions, without diagnosing the Renying.
Zhang Zhongjing, based on the *Neijing*'s discussion of Ge Yang syndrome when the Renying Stomach pulse is four times larger than the Cunkou Lung pulse, adopted Bian Que's method of taking only the Cunkou without diagnosing the Renying. He deduced the *Neijing*'s meaning that Yi Yang constitutes Wai Ge, using the area above the Cunkou to observe the Renying, naming the pulse "Yi" (Overflow) and the syndrome "Ge" (Grid). However, he also stated: "The pulse has Guan and Ge." And again: "These are all True Viscera pulses; even if the person appears healthy, death will occur." This seems to discuss only the pulse and not the syndrome, potentially leading later generations to mistakenly recognize Guan Ge as a pulse morphology rather than a syndrome name. (Generally, "pulse has Guan and Ge" refers to the pulse reaching four times or more as the pulse of the Guan Ge syndrome. "Death without illness" emphasizes the severity of the syndrome. Although the person appears not ill, death is inevitable; having such a pulse implies having such a syndrome, hence Zhang Zhongjing's statement.) This also follows the *Neijing*'s principle that Yi Yang constitutes Wai Ge, clarifying the manifestations of the Wai Ge syndrome. He stated: "The pulse is floating and large. Floating indicates deficiency; large indicates excess. Located at the Cun position, it is Ge; Ge results in vomiting and regurgitation." A floating and large pulse is akin to being four times larger. Floating indicates deficiency of True Qi; large indicates excess of Pathogenic Qi. Located at the Cun position, it is Ge, because above the Cunkou, the pulse transcends the Fish Border, overflowing onto the Fish Border to correspond with the Renying pulse. Vomiting and regurgitation, inability to ingest food, occur because Yang Qi overflows externally, causing the Stomach to completely lose its harmonious nature, unable to rot and ripen food and drink. This inevitably leads to rejection, vomiting, and inability to ingest food, hence named "Ge". (*Zhong Shi Pian* and *Jin Fu Pian* call it Wai Ge; *Liu Jie Zang Xiang Lun* calls it Ge Yang; *Mai Du Pian* calls it Ge; Bian Que and Changsha also call it Ge; Ma Zhonghua and Zhang Jingyue mistakenly regarded Ge as a pulse morphology rather than a syndrome name, and ridiculed Changsha for confusing Ge with the Diaphragm syndrome of the *Neijing*, likely unaware that Ge is the terminal stage of Diaphragm syndrome.) This is the terminal stage of Diaphragmatic Food Retention syndrome.
Zhang Zhongjing, fearing that people might mistake the floating-large pulse for Guan Ge and continue to confuse Guan Ge with a pulse morphology, further detailed the Duyang pulse: "The Duyang pulse is deep and choppy. Deepness causes vomiting and regurgitation with undigested food and drink; choppy texture causes inability to ingest food, named Guan Ge." (Note: Guan Ge can be separated or combined; Ge Yang can also be called Guan Ge, and Guan Yin can also be called Guan Ge, distinguished merely by internal vs. external. Both *Zhong Shi Pian* and *Jin Fu Pian* state that when the Renying pulse is four times larger, both large and rapid, it is named Yi Yang, and Yi Yang constitutes Wai Ge. Bian Que's concept of External Closure and Internal Grid originates from this. When discussing Ge Yang syndrome, it is also referred to as Guan Ge. Hence, Changsha details the Duyang pulse to argue for Ge Yang syndrome, naming it Guan Ge.) Essentially, the Duyang pulse is the Foot-Yangming Stomach meridian pulse located on the foot. (Note: The preface to *Shanghan Lun* states: "Examining the Cun without reaching the Chi, holding the hand without reaching the foot, and not comparing the Renying and Duyang pulses... Renying is at the throat (Upper), Duyang is at the foot (Lower); raising upper and lower places the Cunkou in the middle (Middle). This shows Renying is not on the left hand.") A deep and choppy Duyang pulse indicates Stomach Qi failing to descend and overflowing upward. Thus, when the Renying pulse is four times larger, the upper Renying pulse being large constitutes Guan Ge, and the lower Duyang pulse being deep and choppy also constitutes Guan Ge, thereby confirming Guan Ge as a syndrome.
However, later generations still failed to understand, confused by the *Mai Jing* (Pulse Classic) and *Mai Jue* (Pulse Rhymes), wrongly identifying the left hand as Renying and the right hand as Qi Kou, and following Ma Zhonghua's erroneous claim that Bian Que and Changsha were wrong to distinguish Guan Ge by Cun and Chi positions, asserting Guan Ge is a pulse morphology, not a syndrome name.
Ma Zhonghua stated: "According to *Shanghan Lun*: 'The Cun pulse is floating and large; floating indicates deficiency, large indicates excess; located at the Cun, it is Ge, resulting in vomiting and regurgitation. The Duyang pulse is deep and choppy; deepness causes vomiting and regurgitation with undigested food and drink; choppy texture causes inability to ingest food, named Guan Ge.' The various chapters of the *Neijing* clearly state that when the left-hand Renying pulse is large, from one excess to four excesses, it indicates disease in the Hand and Foot Six Yang meridians, named Ge. Thus, in spring and summer, a slightly large Renying pulse indicates health. Now, Zhang Zhongjing says: 'Located at the Cun, it is Ge,' and 'Ge results in vomiting and regurgitation.' This mistakes the Ge pulse for the Diaphragm syndrome of the *Neijing*. The collection *Ci Shi Nan Zhi* and Li Dongyuan followed this view. Furthermore, they stated: 'When the Qi Kou pulse is four times larger than the Renying, it aligns with the error of the Thirty-Seventh Difficulty of the *Nan Jing*.'"
Note: The Thirty-Seventh Difficulty is based on the *Lingshu: Mai Du Pian* (Meridian Length Treatise), elucidating Guan Ge as a syndrome to support the Third Difficulty. Mr. Ma did not realize Guan Ge is a syndrome, mistaking it for a pulse, hence his contradictory statements. Based on Mr. Ma's theory, identifying the left hand as Renying and Guan Ge as a pulse morphology necessitates regarding Bian Que and Changsha as erroneous. If the left hand is Renying, the Cun and Chi positions cannot distinguish Guan Ge. (Guan is at the Chi, Ge is at the Cun. If discussing Ge via the left-hand Renying, then the right-hand Qi Kou discusses Guan, unrelated to the Chi. This stems from not knowing to observe Renying above the Cunkou and Qi Kou below the Chi, regardless of left or right.) If Guan Ge is a pulse morphology, then vomiting and inability to ingest food cannot constitute the Ge syndrome. This stems from not knowing that the *Neijing* originally defined Guan Ge as a syndrome name. Therefore, Bian Que, fearing later generations would mistake Guan Ge for a pulse morphology, deduced the names of Fu and Yi pulses. (Pulses have names; thus Guan Ge is the syndrome, Yuji overflow is Yi, and entering the Chi is Fu.) Zhang Zhongjing also feared later generations would mistake Guan Ge for a pulse morphology, clarifying the symptoms of the Guan Ge syndrome. (Syndromes have symptoms; thus Guan Ge is not a pulse. Guan means inability to urinate; Ge means vomiting and regurgitation.) Yet Mr. Ma remained oblivious, arguing against this. He claimed the *Neijing* chapters clearly identify the left hand as Renying. However, a specific examination of the *Neijing* reveals no such text. (Wu Hegao also said: "This family pulse method uses imagery, Yang Left, Yin Right,自成一家 (forming its own school), placing Renying at the Left Guan. This seems to be thinking without finding the solution, claiming it forms its own school. It is quite laughable.") All these errors stem from the *Mai Jing* and *Mai Jue*, and subsequent forced interpretations demonstrate such blind faith in error.
Zhang Jingyue stated: "Renying is the Foot-Yangming Stomach meridian, located one cun and five fen below the neck, flanking the laryngeal prominence. 'One excess' and 'two excesses' mean one time and two times larger, referring to comparing Renying and Cunkou, where one may be larger than the other, showing differences of three or four times. The *Jin Fu Pian* states: 'Cunkou governs internal conditions; Renying governs external conditions. They should correspond, moving together, equal in size like a drawn rope. In spring and summer, Renying is slightly larger; in autumn and winter, Cunkou is slightly larger. Such a person is called Ping Ren (Healthy Person).' Thus, when Renying and Cunkou show disparities in excess and deficiency, disease is present. However, Renying observes Yang; therefore, one excess relates to Shaoyang Gallbladder and Sanjiao. Two excesses relate to Taiyang Bladder and Small Intestine. Three excesses relate to Yangming Stomach and Large Intestine. Four excesses and above indicate Yang pulse extremity, with Yin unable to penetrate, hence called Ge Yang."
He added: "I note: The instructions on Guan Ge pulse and syndrome in the Original Canon are very clear. Many people suffer from this, yet physicians through the ages created various names and transmitted them, losing even the fundamental meaning. This is a grave error. What is called Guan Ge is the condition where Yin and Yang are blocked and severed, failing to circulate and harmonize, representing alienation and collapse. Thus, an abundant Renying pulse indicates disease in the Three Yang Fu organs. Yangming circulates Qi among the Three Yang, and the Renying pulse is beside the laryngeal prominence. Hence, ancient methods observed Three Yang Qi at the Renying, as stated in the *Si Shi Qi Pian*: 'Renying observes Yang,' precisely referring to this."
He further added: "I also note: Regarding the Guan Ge pulse, chapters such as *Liu Jie Zang Xiang Lun*, *Mai Du*, *Zhong Shi*, *Jin Fu*, and *Jing Mai* mention it repeatedly, likely fearing it would be difficult to understand, hence reiterating it. It is truly emphasized. Yet few later sages grasped its essence. Did they fail to investigate? The Renying is in the neck, belonging to the Yangming exterior pulse. Thus, a Renying pulse twice as large is called Ge Yang. This is named Guan Ge because Yin and Yang are blocked and severed, Qi fails to nourish each other, and this cannot be changed. But the *Nan Jing* Third Difficulty states: 'Pulses may be excessive, deficient, involve Yin overcoming Yang, be inverted, overflow, be closed, or gridlocked. What does this mean?' Response: 'Anterior to Guan is Yang movement. Pulse should be nine fen deep and floating. Exceeding is Excessive; falling short is Deficient. Rising to Yuji is Overflow, forming External Closure and Internal Grid, a pulse of Yin overcoming Yang.' Hence, Zhang Zhongjing followed this, stating: 'Located at Cun is Ge; Ge results in vomiting and regurgitation.' Since Renying being four times larger is not the Cunkou (observing Renying above Cunkou is why it says 'located at Cun is Ge'; Zhang Jingyue likely did not know this), and mentioning vomiting/regurgitation refers to the Diaphragmatic Food Retention syndrome. (Zhang Jingyue did not know Diaphragmatic Food Retention progresses to Guan Ge.) This syndrome does not necessarily lead to death, so why does the *Neijing* emphasize it so earnestly? Since Wang Shuhe, no one could distinguish this, all discussing Guan Ge by Cun and Chi positions (Zhang Jingyue likely didn't know to observe Renying above Cunkou and Qi Kou below Chi), and claiming the left is Human Grid, causing confusion in later generations and loss of Yin/Yang and Interior/Exterior principles. When Li Dongyuan followed the *Mai Jing*, he identified the left as Renying, stating the Qi Kou pulse is four times larger than Renying, meaning Clear Qi travels the Turbid path, hence called Ge. (Qi Kou being four times larger than Renying means the Cunkou gradually increases to four times above, corresponding to the Renying at the throat. This approaches the intent of the *Neijing*, Bian Que, and Changsha, but refusing to abandon the erroneous left-hand-as-Renying theory, Li Dongyuan was on the verge of realization but misled by the *Mai Jing* and *Mai Jue*, thus failing to awaken. Pity!) Even Zhu Danxi established a separate category for Guan Ge, stating this syndrome often leads to death, Cold in the Upper, Heat in the Lower, with both Cun pulses exceeding four times. How can both Cun pulses exceeding four times indicate Cold in the Upper and Heat in the Lower? His theory deviates further, losing its meaning, leaving students bewildered. Seeking accuracy, is it possible? Only the recent Ma Xuantai realized the errors of others, stating the meaning of Guan Ge is not Diaphragmatic Food Retention or Urinary Retention. (Urinary retention is temporary blockage of fluid passage. Guan is inability to urinate due to fluid exhaustion. Diaphragmatic Food Retention is the beginning of Guan Ge; Ma Zhonghua likely did not know this.) He exclaimed: 'Alas! This violates the teachings of Xuanyuan and Qibo!' Zhang Zhongjing, Wang Shuhe, Li Dongyuan, and Zhu Zhenheng, revered by later practitioners, differ so vastly from the *Neijing*, let alone enabling inferior doctors to know Guan Ge is a pulse, not a disease name, or to judge life/death by Guan Ge pulses, treat Guan Ge syndromes, or treat Diaphragm and Urinary Retention syndromes without error. Mr. Ma's words are true.
However, reading his annotations on various chapters, he did not detail the canonical meaning, erroneously following Wang Shuhe, still identifying the left hand as Renying, effectively erasing the Yangming Stomach meridian, and losing the fundamental meaning of Interior/Exterior and Yin/Yang opposition. This is his repeated error.
Regarding Zhang Jingyue's argument that Renying is at the laryngeal prominence, this is indeed an insightful view. However, not knowing to observe Renying above the two Cun positions, and privately adhering to Ma Xuantai's erroneous theory, he instead deemed Bian Que and Changsha incorrect, causing confusion between Guan Ge syndrome and pulse. If he says "I note: Guan Ge pulse and syndrome," and "I also note: Guan Ge pulse," then calling Guan Ge a syndrome is acceptable, and calling it a pulse is acceptable. (Guan Ge is the syndrome of Fu and Yi pulses; Fu and Yi are the pulses of the Guan Ge syndrome.) If Guan Ge is a syndrome, one should not criticize Zhu Danxi as wrong, but should realize Zhang Zhongjing's intent to clarify Guan Ge symptoms. If Guan Ge is a pulse, it contradicts the *Neijing*'s original intent, and one should realize Bian Que's intent to deduce the names of Fu and Yi pulses. Zhang Jingyue dared not contradict canonical principles but was confused by Ma Zhonghua's erroneous arguments, failing to grasp the intent of Bian Que and Changsha, leading to divergent discussions. He mentioned that chapters like *Liu Jie Zang Xiang Lun*, *Mai Du*, *Zhong Shi*, *Jin Fu*, and *Jing Mai* repeat the points, fearing difficulty in understanding, yet he did not explain the *Neijing*'s reason for emphasizing Renying at the throat. Boasting of his辨析 (analysis), he clung to Renying at the laryngeal prominence to prove others wrong, failing to understand that Bian Que discussed Ge Yang above the Cunkou, deduced the Ge Yang pulse name, identified Yuji overflow as Yi, the pulse of Ge Yang syndrome; and Zhang Zhongjing discussed Ge Yang above the Cunkou, clarified Ge Yang symptoms, identified vomiting and inability to ingest food as Ge Yang syndrome manifestations. Instead, he rejected these, making the pulse clear but the syndrome obscure. With the syndrome obscure, the pulse becomes unclear. Syndrome and pulse mismatching logic is perverse, obscuring the Renying further, which is truly regrettable.