（论二首 律四条）
喻昌曰∶关格之证，自《灵》、《素》以及《难经》，仲景脉法，皆深言之，然无其方也。后世以无成方根据傍，其中玄
言奥义，总不参研，空存其名久矣。间有以无师之智，临证处方，传之于书。眼中金屑，不适于用，可奈之何！谨以《尚
论》之怀，畅言其理。《素问》谓人迎一盛，病在少阳；二盛病在太阳；三盛病在阳明；四盛以上为格阳。寸口一盛，病
在厥阴；二盛病在少阴；三盛病在太阴；四盛以上为关阴。人迎与寸口，俱盛四倍以上为关格。关格之脉，羸不能极于
天地之精气，则死矣。此以三阳之府，三阴之藏，分诊于结喉两旁人迎之位，两手寸口大渊之位。盖随人迎寸口经脉之
行度，而施其刺法也。《灵枢》言刺之从所分，人迎之盛泻其阳，补其所合之阴，二泻一补；从所分寸口之盛泻其阴，补
其所合之阳，二泻一补，皆以上气和乃止。而于用药，则从两手寸关尺三部之脉，辨其脏腑之阴阳。故《灵枢》复言邪
在府，则阳脉不和；阳脉不和，则气留之；气留之则阳气盛矣。阳气太盛，则阴脉不和；阴脉不和，则血留之；血留
之则阴气盛矣。阴气太盛，则阳气不能荣也，故曰关。阳气太盛，则阴气不能荣也，故曰格。阴阳俱盛，不能相荣矣，
故曰关格。关格者，不能尽期而死也。此则用药之权衡，随其脉之尺阴寸阳，偏盛俱盛而定治耳。越人宗之，发为阴乘
阳乘之脉，因推其乘之之极，上鱼为溢，入尺为复，形容阴阳偏而不返之象，精矣。至仲景复开三大法门，谓寸口脉浮
而大，浮为虚，大为实，在尺为关，在寸为格，关则不得小便，格则吐逆。从两手寸口，关阴格阳过盛中，察其或浮或
大，定其阳虚阳实，阴虚阴实，以施治疗。盖于《灵枢》阳太盛则阴不能荣，阴太盛则阳不能荣，以及越人阴乘阳乘之
法，加以浮大之辨，而虚实始得燎然。不尔，关则定为阴实，格则定为阳实矣，抑何从得其微细耶？此一法也。谓心脉
洪大而长，是心之本脉也，上微头小者，则汗出；下微本大者，则关格不通，不得尿；头无汗者可治，有汗者死。此则
深明关格之源，由于五志厥阳之火，遏郁于心胞之内，其心脉上微见头小，亦阳虚之验，下微见本大，亦阳实之验。头
无汗者可治，有汗则心之液外亡，自焚而死矣。在二阳之病发心脾，且不得隐曲，男子少精，女子不月，传为风消，索
泽而不治。况关格之病，精气竭绝，形体毁沮，离绝菀结，忧愁恐怒，五脏空虚，气血离守，厥阳之火独行，上合心神，
同处于方寸之内。存亡之机，间不容发，可不一辨察之乎？此二法也。谓趺阳脉伏而涩，伏则吐呕，水谷不化，涩则食
不得入，名曰关格。诊趺阳足脉，或伏或涩，辨胃气所存几何，伏则水谷入而不化，胃气之所存可知矣；涩
则并其食亦不得入，胃气之所存更可知矣。荣卫之行迟，水谷之入少，中枢不运，下关上格，岂待言哉？此三法也。仲
景金针暗度，有此三法，大概在顾虑其虚矣。因是上下古今，搜采群言，而诸大老名贤，无一论及此证者。惟云岐子述
其阴阳反背之状，传其所试九方，譬如航海万里，得一声气相通之侣，欣慰无似，遑计其短乎？然不欲后人相安其说，
又不忍缄口无言也。其谓阴阳易位，病名关格。胸膈上阳气常在，则热为主病；身半已下阴气常在，则寒为主
病。胸中有寒，以热药治之；丹田有热，以寒药治之。若胸中寒热兼有，以主客之法治之，治主当缓，治客当急。此从
伤寒论胸中有寒，丹田有热立说，实非关格本证。所引《内经》运气治主客之法，亦属无据。至于《灵》、《素》、《难经》、
《金匮》之文，绝不体会，所定诸方，浑入后人恶劣窠臼，观之殊不慊耳。方中小疵，杂用二陈、五苓、枳壳、浓朴、
槟榔、木香是也。方中大疵，杂用片脑、麝香、附子、皂角、牵牛、大黄、朴硝是也。夫阴阳不交，各造其偏，而谓阴
反在上，阳反在下可乎？九死一生之证，而以霸术劫夺其阴阳可乎？仲景之以趺阳为诊者，正欲人调其荣卫，不偏阴偏
阳，一味冲和无忤，听胃气之自为敷布，由一九而二八三七四六，乃始得协于平也。岂一蹴所能几耶？故不问其关于何
而开，格于何而通，一惟求之于中，握枢而运，以渐透于上下，俟其趺阳脉不伏不涩，荣气前通，乃加意于荣；卫气前
通，乃加意于卫；因其势而利导之，庶不与药 格耳。若荣气才通，即求之卫；卫气才通，即求之荣；且为生事喜功，
况躁不能需，亟思一逞乎？夫死里求生之治，须得死里求生之人。嗒然若丧，先熄其五志交煽之火，治吐逆之格，由中
而渐透于上；治不泄之关，由中而渐透于下；治格而且关，由中而渐透于上下。所谓三年之艾，不蓄则不免死亡，蓄之
则免于死亡矣。人亦何为而不蓄之耶？或者病余不立一方，此终身不灵之人也，宁无见其方而反惑耶？不得已姑立进退
黄连汤一方，要未可为中人道也。
（论述两篇，法则四条）
喻昌说：关格这种病证，从《灵枢》、《素问》以及《难经》，到张仲景的脉法，都深入论述过，然而都没有提供现成的方剂。后世因为缺乏成方作为依据和参照，其中玄妙的言语和深奥的含义，总不去研究探讨，空留其名已经很久了。偶尔有凭借无师自通的智慧，在临证时处方用药，并流传于书籍之中。这些如同眼中的金屑，并不适合实际应用，对此又能怎么办呢！我怀着推崇古法的心意，详尽阐述其道理。《素问》说：人迎脉搏动比正常强一倍，病在少阳；强两倍，病在太阳；强三倍，病在阳明；强四倍以上为格阳。寸口脉搏动比正常强一倍，病在厥阴；强两倍，病在少阴；强三倍，病在太阴；强四倍以上为关阴。人迎和寸口脉搏动，都强四倍以上，称为关格。关格的脉象，如果精气衰弱不能承受天地之精气的充盈，就会死亡。这是以三阳之腑、三阴之脏，分别诊察于结喉两旁的人迎穴位置，以及两手寸口大渊穴的位置。大概是随着人迎、寸口经脉的运行度数，而施行针刺疗法。《灵枢》说针刺要遵循所分的部位，人迎脉盛则泻其阳经，补与其相合的阴经，采用二泻一补的方法；寸口脉盛则泻其阴经，补与其相合的阳经，也是二泻一补，都要等到上部气机调和才停止。而在用药方面，则是根据两手寸、关、尺三部脉象，辨别脏腑的阴阳。所以《灵枢》又说邪气在腑，则阳脉不和；阳脉不和，则气机停留；气机停留则阳气盛了。阳气太盛，则阴脉不和；阴脉不和，则血行留滞；血行留滞则阴气盛了。阴气太盛，则阳气不能荣养，所以叫关。阳气太盛，则阴气不能荣养，所以叫格。阴阳都盛，不能相互荣养，所以叫关格。关格病，是不能活到预期寿命而死。这则是用药的权衡标准，随着脉象尺部属阴、寸部属阳，偏盛或俱盛而定治法。扁鹊（越人）遵循这一理论，阐发了阴乘阳、阳乘阴的脉理，进而推究其乘袭的极致，脉气上溢至鱼际为溢脉，入于尺部以下为复脉，形容阴阳偏颇而不返回平衡的状态，非常精妙。到了张仲景又开创三大法门，说寸口脉浮而大，浮表示虚，大表示实，在尺部为关，在寸部为格，关则小便不通，格则呕吐逆反。从两手寸口脉中，观察关阴、格阳过盛中出现的或浮或大的情况，确定阳虚、阳实、阴虚、阴实，从而施治。大概是在《灵枢》所说阳太盛则阴不能荣养，阴太盛则阳不能荣养，以及扁鹊阴乘阳乘之法的基础上，加上对浮、大脉的辨别，虚实才得以清晰明了。不然的话，关就定为阴实，格就定为阳实了，又从哪里能探求其细微之处呢？这是第一种方法。说心脉洪大而长，是心的本脉，如果脉的上部微细头部小，则汗出；下部微细根部大，则关格不通，小便不得排出；头部无汗的可以治愈，有汗的会死亡。这则深刻阐明关格的根源，是由于五志引发的厥阳之火，遏郁在心胞之内，其心脉上部微见头小，也是阳虚的验证，下部微见根大，也是阳实的验证。头部无汗的可以治愈，有汗则心之津液外亡，自身焚毁而死。对于二阳之病发于心脾，且伴有难以言说的隐曲之情，男子精少，女子月经不行，传变为风消，形体消瘦干枯而不治疗的情况。何况关格之病，精气竭绝，形体毁坏沮丧，离绝郁结，忧愁恐惧愤怒，五脏空虚，气血离散失守，厥阳之火独行，上合心神，同处于方寸之心内。存亡的关键，间不容发，能不仔细辨察吗？这是第二种方法。说趺阳脉伏而涩，伏则呕吐，水谷不化，涩则食物不得进入，名叫关格。诊察趺阳足脉，或伏或涩，辨别胃气还剩下多少，伏则水谷进入而不能消化，胃气所剩可知；涩则连食物也不能进入，胃气所剩更可知道。营卫运行迟缓，水谷摄入减少，中枢不运转，下关上格，难道还需要多说吗？这是第三种方法。张仲景暗中传授金针秘诀，有此三法，大概都在顾虑患者的正气虚弱。因此搜采上下古今的各种言论，而各位前辈名贤，没有一人论及此证的。只有云岐子叙述其阴阳反背的状态，流传他所试用的九首方剂，譬如航海万里，得到一声息相通的同伴，欣慰无比，哪还顾及其短处呢？然而不想让后人安心接受这种说法，又不忍心缄口不言。他说阴阳易位，病名关格。胸膈以上阳气常在，则以热为主病；身体半以下阴气常在，则以寒为主病。胸中有寒，用热药治疗；丹田有热，用寒药治疗。如果胸中寒热兼有，用主客法治之，治主当缓，治客当急。这是从《伤寒论》中“胸中有寒，丹田有热”立论，实际上并非关格的本证。所引用的《内经》运气治主客之法，也属于没有依据。至于《灵枢》、《素问》、《难经》、《金匮要略》的原文，完全不加体会，所制定的诸方，混杂入后人的恶劣套路，看了让人很不满意。方中的小毛病，是杂用了二陈汤、五苓散、枳壳、厚朴、槟榔、木香等。方中的大毛病，是杂用了片脑（冰片）、麝香、附子、皂角、牵牛子、大黄、朴硝等。阴阳不交，各自走向偏颇，却说阴反而在上，阳反而在下，可以吗？九死一生的病证，却用霸道的手段劫夺其阴阳，可以吗？张仲景以趺阳脉为诊察重点，正是希望人们调和营卫，不偏阴不偏阳，一味冲和顺遂，听任胃气自行敷布，由一九而至二八三七四六，这才开始符合平和的状态。哪里是一蹴而就就能达到的呢？所以不问其关于何而开，格于何而通，一律从中焦寻求，掌握枢纽而运转，逐渐透达于上下，等到趺阳脉不伏不涩，营气先通，才着重调理营气；卫气先通，才着重调理卫气；顺应病势而引导它，这样才不至于与药物格格不入。如果营气刚通，就去求治卫气；卫气刚通，就去求治营气；况且还有生事求功的心态，急躁不能等待，急切想施展手段吗？从死里求生的治疗，必须得到能从死里求生的人。神情淡漠若有所失，先熄灭五志交煽之火，治疗呕吐逆反的格证，由中焦逐渐透达于上；治疗大便不通的关证，由中焦逐渐透达于下；治疗既关又格的，由中焦逐渐透达于上下。所谓三年的艾草，不蓄积则不免死亡，蓄积了则免于死亡。人为什么不去蓄积呢？或者认为病后不设立一方，这是终身不灵验的人，难道没有看到他的方子反而困惑吗？不得已暂时设立进退黄连汤一方，但这未必适合中等水平的医生使用。
(Let's translate the content into academic English based on the provided Baihua text, adhering to WHO standards where applicable.)
Yu Chang stated: The syndrome of Guan Ge (Obstruction and Rejection) has been discussed in depth from the *Ling Shu* (Spiritual Pivot), *Su Wen* (Basic Questions), and *Nan Jing* (Classic of Difficult Issues), as well as in Zhang Zhongjing’s pulse diagnosis methods; however, no specific formulas were provided. Later generations, lacking established formulas as a basis for reference, did not study the profound theories and subtle meanings contained therein, leaving only the name for a long time. Occasionally, individuals relying on untaught wisdom would prescribe upon clinical presentation and record them in books. These are like gold dust in the eyes—unsuitable for practical use. What can be done? With the intention of honoring ancient principles, I will expound upon the rationale.
The *Su Wen* states: When the Renying (Human Welcome) pulse is one-fold stronger than normal, the disease is in Shaoyang (Lesser Yang); two-fold stronger, it is in Taiyang (Greater Yang); three-fold stronger, it is in Yangming (Bright Yang); four-fold or more stronger indicates Ge Yang (Rejection of Yang). When the Cunkou (Inch Port) pulse is one-fold stronger, the disease is in Jueyin (Terminal Yin); two-fold stronger, it is in Shaoyin (Lesser Yin); three-fold stronger, it is in Taiyin (Greater Yin); four-fold or more stronger indicates Guan Yin (Obstruction of Yin). If both Renying and Cunkou pulses are four-fold or more stronger, it is called Guan Ge. In Guan Ge pulse patterns, if the essence and qi are too depleted to sustain the spirit of heaven and earth, death ensues. This method involves diagnosing the three Yang Fu organs and three Yin Zang organs at the Renying position beside the larynx and the Dayuan position at the Cunkou of both hands. It generally follows the course of the meridians at these points to apply acupuncture.
The *Ling Shu* states that acupuncture should follow the divided locations: if the Renying pulse is excess, drain the Yang and tonify the corresponding Yin using a ratio of two drains to one tonification; if the Cunkou pulse is excess, drain the Yin and tonify the corresponding Yang, also two drains to one tonification. Treatment continues until the Qi in the upper body harmonizes. For herbal medicine treatment, however, one distinguishes the Yin and Yang of the Zang-Fu organs by examining the Cun, Guan, and Chi positions of both wrists. Thus, the *Ling Shu* further states: when pathogenic factors are in the Fu organs, the Yang pulses are discordant; discordance in Yang pulses leads to Qi stagnation; Qi stagnation results in excessive Yang. Excessive Yang causes Yin pulses to become discordant; discordance in Yin pulses leads to Blood stasis; Blood stasis results in excessive Yin. Excessive Yin prevents Yang from nourishing, hence termed Guan (Obstruction). Excessive Yang prevents Yin from nourishing, hence termed Ge (Rejection). When both Yin and Yang are excessive and cannot mutually nourish each other, it is called Guan Ge. Patients with Guan Ge do not reach their natural lifespan before dying. This serves as the standard for herbal prescription, determining treatment based on whether the Yin (Chi position) or Yang (Cun position) is excessively strong or both are excessive.
Bian Que (Yue Ren) adopted this theory, elaborating on the pulses of Yin overacting on Yang and Yang overacting on Yin. He deduced the extremes of this overaction: when pulse Qi overflows to the fish margin (thenar eminence), it is called Yi (Overflow); when it enters below the Chi position, it is called Fu (Return). This accurately describes the state of Yin and Yang deviating without returning to balance.
Zhang Zhongjing then opened three major diagnostic approaches:
1. He stated that if the Cunkou pulse is floating and large, floating indicates deficiency and large indicates excess. If found at the Chi position, it is Guan; if at the Cun position, it is Ge. Guan manifests as urinary retention, while Ge manifests as vomiting and reflux. By observing whether the pulse is floating or large within the context of excessive Guan Yin or Ge Yang, one determines whether there is Yang deficiency/excess or Yin deficiency/excess to guide treatment. This builds upon the *Ling Shu*’s concept that extreme Yang prevents Yin from nourishing and vice versa, and Bian Que’s theory of mutual overaction, adding the differentiation of floating and large pulses to clarify deficiency and excess. Otherwise, Guan would simply be defined as Yin excess and Ge as Yang excess, making it impossible to discern subtleties. This is the first method.
2. He stated that if the Heart pulse is洪大 (surging and large) yet long, this is the normal pulse of the Heart. If the upper part of the pulse is slightly thin with a small head, sweating occurs. If the lower part is slightly thin but the root is large, Guan Ge occurs with urinary obstruction. If the head has no sweat, the condition is treatable; if there is sweat, it is fatal. This deeply clarifies that the origin of Guan Ge lies in the Fire of Jue Yang generated by the Five Emotions, constrained within the Pericardium. A slightly thin upper pulse with a small head indicates Yang deficiency; a slightly thin lower pulse with a large root indicates Yang excess. No sweat on the head indicates treatability; sweat indicates the loss of Heart fluids and self-immolation death. Furthermore, diseases of the Two Yang organs originating in the Heart and Spleen, accompanied by hidden distress, male seminal scarcity, and female amenorrhea, may progress to Feng Xiao (wind emaciation) and wasting away if untreated. Given that Guan Ge involves exhaustion of essence and Qi, destruction of the physical form, separation and knotting, sorrow, fear, and anger, emptiness of the five Zang organs, and dispersion of Qi and Blood, with Jue Yang Fire acting alone and merging with the Spirit in the heart, the difference between life and death is minute. Must we not examine this carefully? This is the second method.
3. He stated that if the Duyang (Foot-Yang) pulse is deep (Fu) and choppy (Se), deepness indicates vomiting and undigested food/water, while choppy indicates inability to ingest food, named Guan Ge. Diagnosing the Foot-Yang pulse, whether deep or choppy, reveals how much Stomach Qi remains. Deepness implies ingested food/water is not digested, revealing the state of Stomach Qi; choppyness implies even food cannot enter, further confirming the depletion of Stomach Qi. With sluggish Ying-Wei circulation and reduced intake, the central pivot fails to transport, leading to lower obstruction and upper rejection. This needs no further explanation. This is the third method.
Zhang Zhongjing’s subtle transmission of these three methods primarily concerns the protection of deficient Zheng Qi (Upright Qi). Searching through ancient and modern texts, few masters addressed this syndrome. Only Yun Qizi described the state of reversed Yin and Yang and transmitted nine tested formulas. Like finding a companion with shared resonance after sailing ten thousand miles, one feels immense joy and overlooks flaws. However, unwilling to let later generations accept these views uncritically, and unable to remain silent, I critique them. Yun Qizi claimed that when Yin and Yang reverse positions, the disease is Guan Ge. If Yang Qi constantly resides above the chest/diaphragm, heat is the primary pathology; if Yin Qi constantly resides below the waist, cold is the primary pathology. Cold in the chest is treated with hot herbs; heat in the Dantian is treated with cold herbs. If both cold and heat exist in the chest, the "Master-Guest" method is used: treating the Master requires slowness, treating the Guest requires urgency. This theory stems from the *Shang Han Lun*’s statement "Cold in the chest, Heat in the Dantian," which does not represent the true nature of Guan Ge. The citation of *Nei Jing* fortune-based Master-Guest treatment lacks evidence. Moreover, ignoring the texts of *Ling Shu*, *Su Wen*, *Nan Jing*, and *Jin Gui Yao Lue*, and incorporating poor later-era formulas is unsatisfactory. Minor flaws include the indiscriminate use of Er Chen Tang, Wu Ling San, Zhi Ke, Hou Po, Bing Lang, and Mu Xiang. Major flaws include the use of Bing Pian (Borneol), She Xiang (Musk), Fu Zi (Aconite), Zao Jiao (Gleditsia Sinensis Fruit), Qian Niu (Pharbitis Seed), Da Huang (Rhubarb), and Piao Xiao (Mirabilite). Can one claim that Yin reverses to the top and Yang to the bottom when Yin and Yang fail to interact and each goes to its extreme? Is it appropriate to use coercive methods to rob Yin and Yang in a case with nine deaths for every one survival? Zhang Zhongjing focused on the Duyang pulse precisely to regulate Ying and Wei, avoiding bias toward Yin or Yang, allowing for gentle harmony and letting Stomach Qi distribute naturally, gradually achieving balance. This cannot be achieved instantly. Therefore, regardless of what causes the obstruction or rejection, one must seek the solution in the Middle Jiao, grasp the pivot, and gradually penetrate upward and downward. Only when the Duyang pulse is neither deep nor choppy, and Ying Qi flows forward, should attention focus on regulating Ying; only when Wei Qi flows forward should attention focus on regulating Wei. One must guide according to the trend to avoid conflict with the medication. If one seeks to regulate Wei immediately after Ying flows, or Ying immediately after Wei flows, driven by a desire for quick success and impatience, this is dangerous. Treatment seeking life from death requires a practitioner capable of such patience. One must appear detached, first extinguishing the fire stirred by the Five Emotions. To treat Ge (vomiting), penetrate gradually from the Middle to the Upper; to treat Guan (constipation/urinary retention), penetrate gradually from the Middle to the Lower; to treat both, penetrate gradually from the Middle to both Upper and Lower. As the saying goes, three-year-old mugwort, if not stored, leads to death; if stored, it saves life. Why should humans not store [virtue/patience]? Perhaps because he did not establish a formula for post-illness recovery, his methods remained ineffective throughout his life. Did seeing his formulas cause confusion? Reluctantly, I have tentatively established the Tui Jin Huang Lian Tang (Advance-Retreat Coptis Decoction), though it may not be suitable for average practitioners.