关格之说不一，而各有理。经谓寸口（即手寸关尺之总名）主中，（寸口本肺脉，属脏，以候内。）
人迎（在结喉旁，乃胃脉，属腑，以候外）主外，两者相应，大小齐等。春夏人迎微大，秋冬寸
口微大，曰平人。（说见四诊。）人迎一盛，（大于气口一倍也。下仿此。）病在
足少阳，一盛而躁，
病在手少阳。二盛，病在足太阳，二盛而躁，病在手太阳。三盛，病在足阳明，三
盛而躁，病在手阳明。四盛，且大且数，（数即躁也。）名曰溢阳，（阳盛而溢。）为外格。
（拒饮食
不得入。）寸口脉一盛，病在足厥阴，一盛而躁，病在手厥阴。二盛，病在足少阴，二
盛而躁，病在手少阴。三盛，病在足太阴，三盛而躁，病在手太阴。四盛，且大且
数，名曰溢阴，为内关，（溲溺不通。）皆死不治。人迎、寸口俱盛四倍以上，命曰关格，
与之短期。（按此皆以躁数为言，是主热立论，乃举隅之词。观其又一条云∶必审按寒热，
以验脏腑之病，可知
此证有寒有热矣。）又谓五脏不和，则七窍（耳目口鼻）不通，（气不通矣。）六腑不和，则留结为痈。
故邪在腑，则阳脉不和，不和则气留而阳盛矣。气太盛，则阴脉不利，（此二句，当根据《难
经》云∶邪在脏，则阴脉不利，接下不利则血留而阴盛，与上文邪在腑对讲。今云阳太盛则阴
不利者，以见阴阳相
关，彼此脉络传注之理，古人文本往往如此。）不利则血留而阴气盛矣。阴气太盛，阳气不能
荣也，（气血相和则荣茂，今血不行，而邪聚于阴经，则阳气不能与通。）故曰关阳。（言闭关不使阳
入也。）阳气太盛，则阴气不能荣也，故曰格阴。（拒格其阴不得入也。）阴阳俱盛，不得相
荣，故曰关格，不得尽期而死。按经言阴阳之邪，偏盛或俱盛，则其经脉不和，
而见于人迎、寸口如此。后世独诊寸口，故秦越人以上鱼为溢，（阳被阴格，脉从寸
溢上鱼际也。）为外关内格；（外阳为内阴所拒格，不得下通，如被关闭然。）入尺为覆，（
阴被阳格，脉从尺覆，
向臂上。覆，退却之义。）为内关外格。（阴被格不上通，如被关闭也。）仲景则谓，寸口脉
浮而大，浮
为虚，（正气内虚，故外浮越。）大为实。（邪气实也。）在尺为关，在寸为格，关则不得小便，格
则吐逆。（此与越人同意。越人以脉之长而有余言，仲景以脉之大而有余言，皆邪盛也。）又谓
下微本大者。
（下谓沉分，本谓尺言。沉分脉微小，惟尺略大也。）则为关格不通，不得尿，（沉而微小，阴
虚，尺大寒邪盛。
虚寒无阳则不化，故小便不能出，不言格食者，省文也。）头无汗者可治，有汗者死。（阳脱也。）又
谓趺阳脉伏而涩，（伏则气不行，涩则血不流，无以出纳施化。）伏则吐逆，
水谷不化，涩则食不得入，（血枯胃腕稿也。）名曰关格。（不言小便不通，亦省文也。上
二条以尺、寸言，此以趺阳言也。）详此二家所云，各有其理，亦推展《内经》未尽之
意也。又云岐子谓，关格为阴阳易位，盖阳上阴下，定位也。今寒反在胸
中，舌有白胎，而水浆不下，热在丹田，而小便不通，曰关格。上寒治以热，
下热治以寒。若兼有寒热，分主客治之，治主宜缓，治客宜急，此亦一说也。由此
论之，则夫阳极于上，阴极于下，否隔不交者，当通其阴阳，转否为泰，可知矣。
又张景岳谓，《内经》谓人迎盛四倍以上，为有阳无阴；寸口盛四倍以上，为有阴
无阳；二者俱盛四倍以上，为阳极于上，下焦无阳，阴极于下，上焦无阴，阴阳离
绝。多由酒色伤其精气，以致阳飞于上，阴走于下，脉浮豁无根，散大躁动如此，
为欲脱危候。凡见六脉如弦如革，洪大异常，而且躁数，脉动则身亦动，乳下之虚
里及脐旁，皆有动气，舂舂筑筑，与脉相应。上气微喘，动作则甚，肢体无力。谓
为虚损，则本无咳嗽失血等证，谓为痰火，则又无实邪发热等证，此真阴败竭，元
海无根，最危之候也。彼不纳食，不得小便，自有本证，与关格何涉哉？其说虽与
前人异，然理甚精。（按诸家皆就吐食不溺之证言，而无一定之脉，景岳则指定大数之脉
言，而无吐食不溺
之证，各如其说，施治可也。）
关格这一病名的说法有多种，但各自都有其道理。《内经》说：寸口（即手太阴肺经寸、关、尺三部脉的总称）主候体内脏腑病变，（寸口本为肺之脉，属脏，用以诊察内部情况。）人迎（位于结喉旁，乃足阳明胃经之脉，属腑，用以诊察外部经络病变）主候体表经络病变，两者脉象应当相应，大小相等。春夏季节人迎脉略大，秋冬季节寸口脉略大，称为平人。（此说见于四诊章节。）人迎脉搏动比气口大一倍，（大于气口一倍。以下类推。）病在足少阳胆经；人迎脉大一倍且躁动不安，病在手少阳三焦经。大二倍，病在足太阳膀胱经；大二倍且躁动，病在手太阳小肠经。大三倍，病在足阳明胃经；大三倍且躁动，病在手阳明大肠经。大四倍，且脉形盛大且数急，（数急即躁动的意思。）名为溢阳，（阳气过盛而外溢。）表现为外格证，（拒拒饮食，食物不得入胃。）寸口脉搏动大一倍，病在足厥阴肝经；大一倍且躁动，病在手厥阴心包经。大二倍，病在足少阴肾经；大二倍且躁动，病在手少阴心经。大三倍，病在足太阴脾经；大三倍且躁动，病在手太阴肺经。大四倍，且脉形盛大且数急，名为溢阴，表现为内关证，（小便不通利。）这些情况都属于死证，难以治愈。如果人迎和寸口脉都盛大超过正常四倍以上，命名为关格，预后不良，可告知其剩余寿命。（按：以上论述主要依据脉象的躁动和数急来立论，这是针对热证而言的，是举例说明。看它另一条说：“必须审察寒热，以验证脏腑病变”，可知此证既有寒证也有热证。）又说五脏功能不和，则七窍（眼、耳、口、鼻）不通，（气机不通畅了。）六腑功能不和，则邪气留滞凝结而成痈肿。所以邪气在腑，则阳脉不和，不和则气机留滞而阳气偏盛。阳气太盛，则阴脉不利，（这两句，应当根据《难经》所说：“邪在脏，则阴脉不利”来接下文“不利则血留而阴盛”，与上文“邪在腑”相对照。现在说“阳太盛则阴不利”，是为了显示阴阳相互关联、彼此脉络传注的道理，古人的文章往往如此表述。）阴脉不利则血液留滞而阴气偏盛。阴气太盛，阳气不能与之相荣养，（气血调和则荣茂，现在血行不畅，而邪气聚于阴经，则阳气不能与之相通。）所以称为关阳。（意思是闭关不让阳气进入。）阳气太盛，则阴气不能与之相荣养，所以称为格阴。（拒绝格挡阴气使其不得进入。）阴阳俱盛，不能相互荣养，所以称为关格，最终会因无法维持生命期限而死。按经文所言，阴阳之邪，或偏盛或俱盛，则其经脉不和，从而在人迎、寸口脉象上表现出上述情况。后世唯独诊察寸口脉，所以秦越人（扁鹊）认为，脉气从寸口溢出到鱼际，称为溢脉，（阳气被阴气格拒，脉气从寸口溢出至鱼际。）表现为外关内格；（体表的阳气被体内的阴气所格拒，不能向下通行，如同被关闭一样。）脉气从尺部向上覆向臂部，称为覆脉，（阴气被阳气格拒，脉气从尺部覆向手臂上方。覆，有退却、覆盖的意思。）表现为内关外格。（阴气被格拒不能向上通畅，如同被关闭一样。）张仲景则认为，寸口脉浮而大，浮表示虚，（正气内虚，所以向外浮越。）大表示实。（邪气实盛。）脉见于尺部为关，脉见于寸部为格，关则导致小便不通，格则导致呕吐逆反。（这与扁鹊的观点一致。扁鹊是从脉气长而有余的角度来说，仲景是从脉形大而有余的角度来说，都是指邪气盛。）又说，如果沉取脉微小，而尺部脉略大者，（下指沉取部位，本指尺部。沉取脉微小，仅尺部略微大。）则为关格不通，小便不能排出，（沉取微小，表示阴虚，尺部大表示寒邪盛。虚寒无阳则气化无力，所以小便不能出，这里不说饮食格拒，是省略写法。）头部没有汗出的可以治疗，有汗出的则死。（阳气脱失。）又说趺阳脉伏而涩，（伏则气机不行，涩则血液不流，无法进行出纳和施化。）伏脉则导致呕吐逆反，水谷不消化，涩脉则导致食物不得入咽，（血枯胃脘干枯。）命名为关格。（这里不说小便不通，也是省略写法。前两条以尺、寸脉言，这条以趺阳脉言。）详细考察这两家的说法，各有其道理，也是推展《内经》未尽之意。又有人引用岐伯之子（此处疑为后人托名或特定医家言论，原文作“岐子谓”）的说法，认为关格是阴阳易位，盖阳气应居上、阴气应居下，这是定位。现在寒气反而在胸中，舌上有白苔，而水浆不下，热邪在丹田，而小便不通，这叫关格。上寒用热药治，下热用寒药治。如果兼有寒热，区分主客来治疗，治主证宜缓，治客证宜急，这也是一说。由此论证，那么阳极于上，阴极于下，否塞不交的情况，应当通调阴阳，扭转否塞转为泰和，就可以知道了。另外张景岳认为，《内经》说人迎脉盛四倍以上，是有阳无阴；寸口脉盛四倍以上，是有阴无阳；两者都盛四倍以上，是阳极于上，下焦无阳，阴极于下，上焦无阴，阴阳离绝。多由酒色损伤精气，导致阳气飞越于上，阴气走泄于下，脉象浮豁无根，散大躁动如此，这是欲脱的危重证候。凡是见到六脉如弦如革，洪大异常，而且躁数，脉动则身体也随之颤动，乳下的虚里及脐旁，都有动气，跳动剧烈，与脉搏相应。上部气息微喘，动作时加重，肢体无力。说是虚损，则原本没有咳嗽失血等症状；说是痰火，则又没有实邪发热等症状，这是真阴败竭，元海无根，是最危险的证候。那些不能进食，不能小便，自有其本证，与关格有什么关系呢？他的说法虽然与前人不同，但道理很精辟。（按：各家都是就呕吐饮食、不通小便的症状而言，而没有固定的脉象；张景岳则指定大数之脉而言，而没有呕吐饮食、不通小便的症状，各依其说进行治疗即可。）
The concept of "Guan Ge" (Obstruction and Rejection) varies in interpretation, yet each has its rationale. The *Classic of Internal Medicine* (*Neijing*) states: Cun Kou (the collective term for the Cun, Guan, and Chi positions on the radial artery) governs the interior, (Cun Kou originally belongs to the Lung meridian, associated with Zang organs, used to inspect internal conditions.) Ren Ying (located beside the Adam's apple, belonging to the Stomach meridian, associated with Fu organs, used to inspect exterior conditions) governs the exterior. The two should correspond, with equal magnitude. In spring and summer, Ren Ying is slightly larger; in autumn and winter, Cun Kou is slightly larger; this is called a healthy person. (This explanation is found in the chapter on Four Diagnostic Methods.) If Ren Ying is one-fold larger than Qi Kou, (meaning one times larger than Qi Kou. The following follows this pattern.) the disease is in the Foot Shaoyang Gallbladder Meridian; if Ren Ying is one-fold larger and restless, the disease is in the Hand Shaoyang Sanjiao Meridian. If two-fold larger, the disease is in the Foot Taiyang Bladder Meridian; if two-fold larger and restless, the disease is in the Hand Taiyang Small Intestine Meridian. If three-fold larger, the disease is in the Foot Yangming Stomach Meridian; if three-fold larger and restless, the disease is in the Hand Yangming Large Intestine Meridian. If four-fold larger, and both large and rapid, (Rapid means restless.) it is named Yi Yang (Overflowing Yang), (Yang qi is excessive and overflowing.) manifesting as Wai Ge (Exterior Rejection), (Rejecting food and drink, preventing entry.) If Cun Kou is one-fold larger, the disease is in the Foot Jueyin Liver Meridian; if one-fold larger and restless, the disease is in the Hand Jueyin Pericardium Meridian. If two-fold larger, the disease is in the Foot Shaoyin Kidney Meridian; if two-fold larger and restless, the disease is in the Hand Shaoyin Heart Meridian. If three-fold larger, the disease is in the Foot Taiyin Spleen Meridian; if three-fold larger and restless, the disease is in the Hand Taiyin Lung Meridian. If four-fold larger, and both large and rapid, it is named Yi Yin (Overflowing Yin), manifesting as Nei Guan (Interior Obstruction), (Urination is blocked.) All these cases are fatal and incurable. If both Ren Ying and Cun Kou are more than four times larger than normal, it is named Guan Ge, and a short life expectancy can be predicted. (Note: These descriptions focus on restlessness and rapidity, establishing a theory based on Heat patterns, serving as illustrative examples. Observing another passage stating: "One must carefully examine cold and heat to verify Zang-Fu diseases," it is known that this syndrome involves both Cold and Heat.) It is also stated that when the five Zang organs are not harmonious, the seven orifices (eyes, ears, mouth, nose) become blocked, (Qi mechanism is obstructed.) When the six Fu organs are not harmonious, pathogens remain and knot to form abscesses. Therefore, if pathogens are in the Fu organs, the Yang meridians are disharmonious; disharmony leads to Qi stagnation and Yang excess. Excessive Yang makes the Yin meridians unfavorable; (These two sentences should follow the statement in the *Classic of Difficult Issues* (*Nanjing*): "If pathogens are in the Zang organs, the Yin meridians are unfavorable," connecting to "unfavorable leads to blood stasis and Yin excess," contrasting with the preceding text about pathogens in Fu organs. The current text says "excessive Yang makes Yin unfavorable" to illustrate the interconnection of Yin and Yang and the transmission of meridians, a common feature in ancient texts.) Unfavorable Yin leads to blood stasis and Yin excess. Excessive Yin prevents Yang from nourishing it, (When Qi and Blood are harmonious, they flourish; now blood flow is impaired, and pathogens gather in Yin meridians, so Yang cannot communicate with them.) thus it is called Guan Yang (Closing Yang). (Meaning closing the gate to prevent Yang from entering.) Excessive Yang prevents Yin from nourishing it, thus it is called Ge Yin (Rejecting Yin). (Repelling Yin so it cannot enter.) When both Yin and Yang are excessive and cannot nourish each other, it is called Guan Ge, leading to death before the natural lifespan ends. According to the classics, when Yin-Yang pathogens are either excessively dominant or mutually excessive, their meridians become disharmonious, manifesting in Ren Ying and Cun Kou as described above. Later generations only palpate Cun Kou, so Qin Yue (Bian Que) considered pulse overflowing from Cun to Yu Ji (fish belly) as Yi Pulse, (Yang is rejected by Yin, pulse overflows from Cun to Yu Ji.), manifesting as Wai Guan Nei Ge (Exterior Obstruction, Interior Rejection); (Exterior Yang is rejected by Interior Yin, unable to descend, like being closed off.) Pulse covering from Chi towards the arm as Fu Pulse, (Yin is rejected by Yang, pulse covers from Chi upwards. Fu means retreat or cover.), manifesting as Nei Guan Wai Ge (Interior Obstruction, Exterior Rejection). (Yin is rejected and cannot ascend, like being closed off.) Zhang Zhongjing stated that if Cun Kou pulse is floating and large, Floating indicates deficiency, (Internal deficiency of righteous Qi causes external floating.) Large indicates excess. (Pathogenic excess.) Located at Chi, it is Guan (Obstruction); located at Cun, it is Ge (Rejection). Guan results in inability to urinate; Ge results in vomiting and reflux. (This agrees with Bian Que. Bian Que spoke of pulse length and surplus; Zhongjing spoke of pulse magnitude and surplus; both indicate pathogenic excess.) He also stated that if the deep pulse is minute but the Chi position is relatively large, (Deep refers to the deep pressure level; Ben refers to Chi. Deep pulse is minute, only Chi is slightly large.) it is Guan Ge obstruction, inability to urinate, (Deep and minute indicates Yin deficiency; Chi large indicates Cold pathogen excess. Deficiency-Cold without Yang fails to transform fluids, hence urine cannot exit. The mention of food rejection is omitted for brevity.) If the head has no sweat, it is treatable; if there is sweat, it is fatal. (Yang collapse.) He also stated that if the Zu Yang (Dazu) pulse is hidden and choppy, (Hidden means Qi does not move; Choppy means Blood does not flow, unable to perform intake/output and transformation.) Hidden pulse leads to vomiting and reflux, undigested food and water; Choppy pulse leads to inability to ingest food, (Blood dryness, stomach wall withered.) named Guan Ge. (Inability to urinate is not mentioned, also for brevity. The previous two points discussed Chi and Cun; this one discusses Zu Yang.) Examining these two schools of thought, each has its logic, extending the未尽 (unfinished) meaning of the *Neijing*. Another view attributed to Qi Bo's son states that Guan Ge is the reversal of Yin and Yang positions. Yang should be upper, Yin lower, which is the fixed position. Now, Cold is in the chest, tongue has white coating, and fluids cannot pass down; Heat is in the Dantian, and urination is blocked; this is called Guan Ge. Upper Cold is treated with Hot methods; Lower Heat is treated with Cold methods. If Cold and Heat coexist, treat the primary and secondary factors separately; treating the primary should be gradual, treating the secondary urgent. This is another perspective. From this argument, it is clear that when Yang extremity is at the top and Yin extremity is at the bottom, causing blockage and lack of interaction, one should regulate Yin and Yang, turning Pi (Stagnation) into Tai (Peace). Zhang Jingyue further argued that the *Neijing* states Ren Ying exceeding four times is having Yang without Yin; Cun Kou exceeding four times is having Yin without Yang; both exceeding four times is Yang extremity at the top (no Yang in Lower Jiao) and Yin extremity at the bottom (no Yin in Upper Jiao), representing Yin-Yang separation. This often results from alcohol and sexual excess damaging Essence and Qi, causing Yang to fly upward and Yin to drain downward, resulting in floating, rootless, scattered, large, and restless pulses, indicating impending collapse. Whenever six pulses are wiry or like leather, exceptionally洪大 (Surging-Large), and restless/rapid, where pulse movement causes body tremors, and there is pulsation at Xu Li (below the nipple) and beside the umbilicus, beating vigorously corresponding to the pulse, accompanied by slight panting, worsening with movement, and limb weakness: if diagnosed as Xu Sun (Deficiency Damage), there are typically no cough or hemoptysis symptoms; if diagnosed as Tan Huo (Phlegm-Fire), there are no excess Heat fever symptoms. This represents true Yin exhaustion and Yuan Hai (Sea of Origin) lacking roots, a critical condition. Those who cannot eat or urinate have their own primary syndromes; what does this have to do with Guan Ge? Although his theory differs from predecessors, the reasoning is profound. (Note: Previous experts focused on symptoms of vomiting/reflux and urinary retention without specifying a fixed pulse; Jingyue specified large/rapid pulses without focusing on vomiting/retention symptoms. Treatment can proceed according to either theory.)