喻嘉言曰∶关格之症，自《灵》、《素》以及《难经》、仲景脉法，皆深言之，然无其方也。《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，不能极于大地之精气，则死矣。
《灵枢》复言邪在腑则阳脉不和，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，故曰关格。关格者，不能尽期而死也。
越人宗之，发为阴乘、阳乘之脉，因推其阴乘之极，上为鱼溢，入尺为覆，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，从两手关阴格阳过盛中，察其或浮或大，定其阴虚阴实。阳虚阳实，以施治疗。盖于《灵枢》阴阳
太盛不能相荣，以及越人阳乘阴乘之法，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。此一法也。
谓心脉太盛而长，是其本脉。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，此一法也。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，况关格之病，精气竭绝，五脏空虚，厥阳之火独行，上合心神，
存亡之机，间不容发。此一法也。
谓趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名曰关格。诊趺阳足脉，或伏或涩，胃
气之所存可知矣。荣卫之行迟，水谷之入少，中枢不运，下关上格，讵待言哉？此一法也。仲景以此三法言
关格，大概在顾虑其虚矣。
后世云岐子述其阴阳反背之状，传其所试九方，其谓阴阳易位，病名关格，膈以上阳气常在，则热
为主病；身半以下阴气常在，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，实非关格本症。
所引运气治主客之法，亦属无据。于《素》、《难》、《金匮》之文，绝不体会，所定诸方，又入后人恶劣
窠臼，殊不慊人。夫阴阳不交，各造其偏，而谓阴反在上，阳反在下，可乎？九死一生之症，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，听胃气之自为敷布，乃始得协于平也。故不
问其关于何开，格于何通，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，乃因其势而
利导之，庶不与药扦格耳。惟治吐逆之格，由中而渐透于上；治不溲之关，由中而渐透于下；治格而且关，
由中而渐透于上下可耳。
进退黄连汤肾气丸治法论
黄连汤，仲景治伤寒之方也。伤寒胸中有热，胃中有邪气，腹中痛，欲呕吐者，黄连汤主之。以
其胃中有邪气，阻遏阴阳升降之机，而不交于中土，于是阴不得升，而独滞于下为下寒，阳不得降，而独治于
上为胸中热，欲呕吐。与此汤以升降阴阳，固然矣。
而湿家下之，舌上如胎者，丹田有热，胸中有寒，亦用此方，何耶？盖伤寒分表、里、中三法，表里
之邪俱盛，则从中而和之。故有小柴胡汤之和法，以人参、甘草、半夏、生姜，大枣助胃之中，但加柴胡一
味透表，黄芩一味透里，听胃气之升者，带柴胡出表，胃气之降，带黄芩入里，一和而表里之邪尽服。
其有未尽者，加工治之，不相扦格矣。至于
丹田胸中之邪，则在于上下，而不为表里，即变柴胡为黄连汤，和其上下，以桂枝易柴胡，以黄连易黄
芩，以干姜易生姜，亦听胃气之上下敷布，故不问上热下寒，上寒下热，皆可治之也。
夫表里之邪，则用柴胡、黄芩；上下之邪，则用桂枝、黄连。表里之邪，则用生姜之辛以散之；上
下之邪，则用干姜之辣以开之。仲景圣法灼然矣。前论所谓求之于中，握枢而运，以渐透于上下，俟其
荣气前通，卫气后通，而为进退也。
夫格则吐逆，进而用此方为宜。盖太阳主开，太阳不开，则胸中窒塞，食不得入，入亦复出，以桂枝为太
阳经药，和调荣卫而行阳道，故能开之也。至于五志厥阳之火上入，桂枝又不可用矣。用之以火济火，
头有汗而阳脱矣。
其关不得小便，退之之法，从胃气以透入阴分，桂枝亦在所不取。但胃之关门已闭，少阴主阖，少阴之
气不上，胃之关必不开矣。《内经》常两言之，曰肾气独沉，曰肾气不衡。夫真气之在肾中，犹权衡也。
有权有衡，则关门时开时阖；有权无衡，则关门有阖无开矣，小溲亦从何而出耶？是以肾气丸，要亦退之之
中所有事矣。肾气交于胃则关门开，交于心则厥阳之火下伏，有不得不用之时矣。
张景岳曰∶关格一症，在《内经》本言脉体，以明阴阳离绝之危症也。自越人以上鱼为溢，入尺为覆，
以尺寸言关格，已失本经之意。仲景亦云在尺为关，在寸为格。夫《内经》云人迎四倍寸口，四倍既非尺
寸之谓。再至丹溪，则曰此症寒在上热在下，脉两寸俱盛四倍以上，法当吐，以提其气之横格。夫两寸俱盛
四倍，又安得谓寒在上耶？且脉大如此，则浮豁无根，其虚可知，又堪吐乎？谬而又谬，莫此甚矣。
夫关格症者，在《内经》本以人迎察六腑之阳，寸口察五脏之阴。人迎盛至四倍以上者，此阳明经
孤阳独见，水不济火也，故曰格阳。格阳者，阴格于阳也，气口盛至四倍以上，此太阴经元阴无主，气不归
精也，故曰关阴。关阴者，阳关于阴也。若人迎、寸口俱盛至四倍以上，且大且数，此其阳气不藏，故阴中
无阳；阴气不升，故阳中无阴。阴阳相离，故名关格也。
《脉度篇》曰∶阴气太盛，则阳气不能荣，故曰关；阳气太盛，则阴气弗能荣，故曰格。阴阳俱盛，
不能相荣，故曰关格。关格者，不得尽期而死也。是可见阳病极于阳分，阴病极于阴分也。凡阳盛于阳，
似乎当泻，而阴分见阴，又不可泻∶阴极于阴者，似乎当补，而阳分见阳，又不可补。病至此，阳自阳，
阴自阴，上下痞膈，两顾不能，补泻不可，有死而已。
此与真寒假热、假热真寒之症大有不同。凡见此症，总由酒色伤肾，情欲伤精以致阳不守舍，故脉沉气
露，亢极如此。真阴败竭，元海无根，诚亢悔之象，最危之危也。
然关格诊法，后人不察人迎，但寸口为脉之大会，脉见于彼，未有不见于此者。若其弦大至极，四倍以
上，且大且数者，便是关格之脉，不得误认为火症。
盖其症无实邪发热，又无咳嗽失血，所以为异也，然富贵之人及形体丰肥者多有此症，求其所因，
无非耽嗜少艾，中年酒色所致。虽与劳损症若有不同，实则劳损之别名也。
故关格之脉，必弦大至极，夫弦者为中虚，浮大者为阴虚，此肾水大亏，有阳无阴之脉也。治此宜峻
补真阴为主，然又当察虚中之寒热，阴中之阴阳，分别处治。
喻嘉言说：关格这一病症，从《灵枢》、《素问》到《难经》以及张仲景的脉法，都进行了深入的论述，然而都没有给出相应的方剂。《素问》中说，人迎脉比寸口脉大一倍，病在少阳；大两倍，病在太阳；大三倍，病在阳明；大四倍以上为格阳（阳气亢盛于外）；寸口脉比人迎脉大一倍，病在厥阴；大两倍，病在少阴；大三倍，病在太阴；大四倍以上为关阴（阴气闭塞于内）。如果人迎脉和寸口脉都盛大四倍以上，就称为关格。关格的脉象表现为羸弱，无法承受大地精气的滋养，患者就会死亡。
《灵枢》又说，邪气在腑则阳脉不和，阳脉不和则气机留滞，气机留滞则阳气过盛。阳气过盛则导致阴脉不和，阴脉不和则血液留滞，血液留滞则阴气过盛。阴气过盛，则阳气不能濡养它，所以称为“关”；阳气过盛，则阴气不能濡养它，所以称为“格”；阴阳都过盛，不能相互濡养，所以称为“关格”。患关格病的人，活不到预定的寿命就会死去。
扁鹊（越人）遵循这一理论，提出了阴乘、阳乘的脉象，进而推演阴乘的极端情况，向上发展为鱼溢脉，向下深入尺部为覆脉，形象地描述了阴阳偏颇而不能恢复平衡的状态，非常精妙。
到了张仲景，又开辟了三大法门，他说：寸口脉浮而大，浮表示虚，大表示实。脉见于尺部为关，脉见于寸部为格。关则小便不通，格则呕吐逆乱。从两手关部阴格阳过盛的脉象中，观察其或浮或大的变化，确定阴虚还是阴实，阳虚还是阳实，从而实施治疗。这是在《灵枢》阴阳过盛不能相互濡养，以及扁鹊阳乘阴乘的方法基础上，加上对浮大脉象的辨别，虚实之理才变得清晰明了。否则，关就被定为阴实，格就被定为阳实了。这是第一种方法。
又说：心脉过于盛大且长，这是心的本脉。如果脉象上部微小头部细小，则会汗出；下部微小但根部粗大，则会导致关格不通，小便不得排出。头部无汗的可以治愈，有汗出的则死亡。
这深刻阐明了关格的根源，是由于五志引发的厥阳之火，郁结在心包之内。其心脉上部微见头小，也是阳虚的表现；下部微见根部粗大，也是阳实的表现。头部无汗的可以治愈，如果有汗出，则是心液外泄，体内自焚而死，这是第二种方法。对于二阳（胃与大肠）的疾病发于心脾，且伴有难以启齿的情志不畅，男子精少，女子月经停闭，传变为风消、索泽等症，何况关格之病，精气枯竭，五脏空虚，厥阳之火独行，上扰心神，存亡之机，间不容发。这是第三种方法。
又说：趺阳脉伏而涩，伏脉则呕吐逆乱，水谷不化；涩脉则饮食难以下咽，这叫做关格。诊察趺阳足脉，无论是伏脉还是涩脉，就可以知道胃气的存亡了。营卫运行迟缓，水谷摄入减少，中焦枢纽不运，下关上格，这还用得着多说吗？这是第四种方法。张仲景用这三种方法论述关格，大概都在顾虑患者的正气虚弱。
后世的云岐子描述了阴阳反背的状态，传授了他试用的九首方剂。他认为阴阳位置互换，病名关格，膈以上阳气常在，则以热为主病；身半以下阴气常在，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。治主证当缓，治客证当急。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症。所引用的运气学说中治主客的方法，也属于没有依据。对于《素问》、《难经》、《金匮要略》中的原文，完全没有体会，所确定的诸方，又落入后人恶劣的窠臼，实在让人不满意。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？这是九死一生的重症，却用霸道的手段劫夺其阴阳，可以吗？
张仲景以趺阳脉作为诊断依据，正是希望人们调理营卫，不偏阴也不偏阳，听任胃气自行敷布，这样才能达到平衡。所以不问关在于何处开，格在于何处通，一律从中焦寻求对策，掌握中枢而运转，逐渐透达于上下。等到趺阳脉不再伏涩，再顺势利导，这样才不会与药物格格不入。只有治疗呕吐逆乱的格证，由中焦逐渐透达于上；治疗小便不通的关证，由中焦逐渐透达于下；治疗既关又格的病证，由中焦逐渐透达于上下即可。
黄连汤，是张仲景治疗伤寒的方剂。伤寒病胸中有热，胃中有邪气，腹中痛，想呕吐的，用黄连汤主治。因为胃中有邪气，阻碍了阴阳升降的机制，使得阴阳不能在中土交汇，于是阴气不能上升，独自停滞于下成为下寒；阳气不能下降，独自治理于上成为胸中热，想要呕吐。给予此汤以升降阴阳，固然正确。
但是，湿家误用下法后，舌上如有一层胎垢，丹田有热，胸中有寒，也用这个方子，为什么呢？大概伤寒分为表、里、中三法，表里之邪都盛时，则从中焦调和。所以有小柴胡汤的和法，用人参、甘草、半夏、生姜、大枣助益胃气之中，只加一味柴胡透达表邪，一味黄芩透达里邪，听任胃气升发者，带着柴胡出表；胃气降浊者，带着黄芩入里，一经调和，表里之邪便全部消除。如果有未尽的邪气，再加工治疗，就不会格格不入。至于丹田和胸中之邪，则位于上下，而不属于表里，即把柴胡汤变为黄连汤，调和上下，用桂枝代替柴胡，用黄连代替黄芩，用干姜代替生姜，也是听任胃气在上下敷布，所以不论上热下寒，还是上寒下热，都可以治疗。
表里之邪，用柴胡、黄芩；上下之邪，用桂枝、黄连。表里之邪，用生姜的辛味来发散；上下之邪，用干姜的辣味来开通。张仲景的圣法显然如此。前文所说的求之于中，掌握中枢而运转，逐渐透达于上下，等待营气先通，卫气后通，从而进行进退调整。
格证表现为呕吐逆乱，进而使用此方为宜。因为太阳主开，太阳不开，则胸中窒塞，食物不能进入，即使进入也会复出。桂枝是太阳经药，能调和营卫而行阳道，所以能开通它。至于五志引发的厥阳之火上行，桂枝就不可以用了。用桂枝如同以火救火，会导致头部出汗而阳气脱失。
关证表现为小便不通，退之的方法，是从胃气透入阴分，桂枝也在所不用。但是胃的关门已经关闭，少阴主阖，少阴之气不上行，胃的关门必然打不开。《内经》常两言之，说“肾气独沉”，说“肾气不衡”。真气存在于肾中，就像权衡一样。有权有衡，则关门时而开时而阖；有权无衡，则关门只阖不开，小便又从何而出呢？因此，肾气丸，也是退治关证中所必须考虑的事。肾气交于胃则关门开，交于心则厥阳之火下伏，这是不得不用的时候。
张景岳说：关格这一病症，在《内经》中原是指脉象形态，用以说明阴阳离绝的危重病症。自从扁鹊以上鱼为溢，入尺为覆，以尺寸部位来言关格，就已经失去了本经的原意。张仲景也说在尺为关，在寸为格。《内经》说人迎脉比寸口脉大四倍，四倍既然不是指尺寸部位。再到朱丹溪，则说此症寒在上热在下，脉象两寸俱盛四倍以上，治法应当吐，以提举横格之气。既然两寸脉都盛大四倍，怎么能说是寒在上呢？而且脉象如此之大，则浮豁无根，其虚可知，又怎么能够用吐法呢？错误而又错误，没有比这更严重的了。
夫关格症，在《内经》中原是以人迎脉察六腑之阳，寸口脉察五脏之阴。人迎脉盛大至四倍以上，这是阳明经孤阳独现，水不济火，所以叫格阳。格阳，是阴格拒于阳。气口脉盛大至四倍以上，这是太阴经元阴无主，气不归精，所以叫关阴。关阴，是阳关于阴。如果人迎、寸口脉都盛大至四倍以上，且大而数，这是阳气不藏，所以阴中无阳；阴气不升，所以阳中无阴。阴阳相离，所以名叫关格。
《脉度篇》说：阴气太盛，则阳气不能濡养，所以叫关；阳气太盛，则阴气不能濡养，所以叫格。阴阳俱盛，不能相互濡养，所以叫关格。患关格病的人，活不到预定的寿命就会死去。由此可见，阳病极于阳分，阴病极于阴分。凡是阳盛于阳，似乎应当泻，但阴分见阴，又不可泻；阴极于阴者，似乎应当补，但阳分见阳，又不可补。病到了这一步，阳自阳，阴自阴，上下痞隔，两顾不能，补泻不可，只有死路一条。
这与真寒假热、假热真寒的病症大有不同。凡见到这种病症，总归是由酒色伤肾，情欲伤精，导致阳不守舍，所以脉沉气露，亢极如此。真阴败竭，元海无根，确实是亢悔之象，是最危险的危症。
然而关格的诊法，后人不察人迎脉，只认为寸口是脉之大会，脉见于人迎，没有不见于寸口的。如果脉象弦大至极，四倍以上，且大而数，就是关格的脉象，不要误认为是火症。
大概此症没有实邪发热，也没有咳嗽失血，所以与众不同。然而富贵之人及形体丰肥者多有此症，探求其原因，无非是沉迷于美色，中年纵欲所致。虽然与劳损症似乎有所不同，实际上是劳损的别名。
所以关格的脉，必是弦大至极。弦脉代表中虚，浮大脉代表阴虚，这是肾水大亏，有阳无阴的脉象。治疗此症宜以峻补真阴为主，但又应当察辨虚中之寒热，阴中之阴阳，分别处理。
Yu Jiayan stated: The syndrome of Guan Ge (Obstruction and Rejection) has been discussed in depth from the *Ling Shu* (Spiritual Pivot), *Su Wen* (Basic Questions), to the *Nan Jing* (Classic of Difficult Issues), and Zhang Zhongjing's pulse methods, yet no specific formulas were provided. The *Su Wen* states that when the Renying (Carotid artery) pulse is one times larger than the Cunkou (Radial artery) pulse, the disease is in Shaoyang; two times larger, it is in Taiyang; three times larger, it is in Yangming; four times or more larger indicates Ge Yang (Yang Qi hyperactivity on the exterior). When the Cunkou pulse is one time larger than the Renying pulse, the disease is in Jueyin; two times larger, it is in Shaoyin; three times larger, it is in Taiyin; four times or more larger indicates Guan Yin (Yin Qi obstruction internally). If both the Renying and Cunkou pulses are盛大 (excessively large) by four times or more, it is termed Guan Ge. The pulse of Guan Ge appears emaciated (weak), unable to sustain the essence and Qi of the earth, leading to death.
The *Ling Shu* further states that when pathogenic factors reside in the Fu organs, the Yang pulses become discordant. Discordance in Yang pulses leads to Qi stagnation, which causes excessive Yang Qi. Excessive Yang Qi leads to discordance in Yin pulses, causing Blood stagnation, which results in excessive Yin Qi. When Yin Qi is excessively strong, Yang Qi cannot nourish it, hence termed "Guan" (Obstruction); when Yang Qi is excessively strong, Yin Qi cannot nourish it, 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 will die before their appointed time.
Bian Que (Yue Ren) followed this theory, developing the concepts of Yin Cheng (Yin encroaching) and Yang Cheng (Yang encroaching) pulses. He deduced the extreme of Yin Cheng, describing it as Yu Yi (Fish Overflowing) pulse moving upward and Fu Pulse entering the Chi position, vividly depicting the state of Yin-Yang imbalance without return, which was exquisite.
Zhang Zhongjing then opened three major diagnostic approaches. He stated: If the Cunkou pulse is floating and large, floating indicates deficiency, while large indicates excess. If found at the Chi position, it is Guan; if found at the Cun position, it is Ge. Guan results in urinary retention, while Ge results in vomiting and reflux. By observing whether the pulse is floating or large within the context of Yin-Ge-Yang excess at the Guan positions of both wrists, one can determine Yin deficiency/excess and Yang deficiency/excess to apply treatment. This adds the differentiation of floating and large pulses to the theories of mutual non-nourishment due to excess in the *Ling Shu* and the encroachment methods of Yue Ren, making the distinction between deficiency and excess clear. Otherwise, Guan would be rigidly defined as Yin excess, and Ge as Yang excess. This is the first method.
He also stated: A heart pulse that is excessively large and long is the normal pulse of the Heart. If the upper part of the pulse is small and the head thin, sweating occurs. If the lower part is small but the root is large, Guan Ge obstruction occurs, preventing urination. Cases with no sweat on the head are treatable; those with sweat are fatal.
This deeply elucidates the origin of Guan Ge, stemming from the Fire of Jue Yang generated by the Five Emotions, constrained within the Pericardium. The upper part of the heart pulse appearing small and thin is a sign of Yang deficiency; the lower part appearing large at the root is a sign of Yang excess. No sweat on the head is treatable; sweat indicates the loss of Heart fluids and internal burning death. This is the second method. Regarding diseases of the Two Yangs (Stomach and Large Intestine) originating in the Heart and Spleen, accompanied by unspoken emotional distress, leading to scanty sperm in men and amenorrhea in women, progressing to Wind Consumption and Withered Dryness, let alone Guan Ge where essence and Qi are exhausted, the five Zang organs are empty, and Jue Yang Fire acts alone, disturbing the Spirit. The moment of life and death is imminent. This is the third method.
He further stated: A Duyang (Dadu artery) pulse that is deep (Fu) and choppy (Se) indicates vomiting and reflux with undigested food and water for Fu; inability to swallow food for Se. This is named Guan Ge. Diagnosing the foot pulse at Duyang, whether Fu or Se, reveals the state of Stomach Qi. With sluggish Ying and Wei circulation and reduced intake of water and grain, the central pivot fails to transport, leading to lower obstruction and upper rejection. This is the fourth method. Zhang Zhongjing used these three methods to discuss Guan Ge, largely focusing on the concern for deficiency.
Later, Yun Qizi described the state of reversed Yin and Yang and transmitted nine tested formulas. He claimed that when Yin and Yang exchange positions, the disease is named Guan Ge. If Yang Qi constantly resides above the diaphragm, heat is the primary pathology; if Yin Qi constantly resides below half the body, cold is the primary pathology. Cold in the chest should be treated with hot herbs; Heat in the Dantian should be treated with cold herbs. If both cold and heat exist in the chest, treat using Master-Guest methods. Treating the Master condition requires slowness; treating the Guest condition requires urgency. This theory is based on "Cold in the chest, Heat in the Dantian" from the *Shang Han Lun*, but it does not represent the true syndrome of Guan Ge. The reference to treating Master-Guest conditions via Yungi (Six Qi) theory is unfounded. There is no comprehension of the texts in the *Su Wen*, *Nan Jing*, or *Jin Gui Yao Lue*. The prescribed formulas fall into the bad habits of later generations, which is unsatisfactory. Can it be said that Yin reverses to the top and Yang to the bottom when Yin and Yang do not interact and go to extremes? Is it acceptable to use coercive methods to rob Yin and Yang in a critical condition with nine deaths and one survival?
Zhang Zhongjing’s use of the Duyang pulse diagnosis aims to regulate Ying and Wei, avoiding bias toward Yin or Yang, allowing Stomach Qi to distribute naturally, thereby achieving balance. Thus, regardless of where the Guan or Ge lies, one seeks the solution in the Middle Jiao, grasping the pivot to operate, gradually penetrating up and down. Only when the Duyang pulse is neither Fu nor Se should one guide the condition according to its momentum, avoiding conflict with the medicine. For treating Ge (vomiting/reflux), penetrate from the middle to the upper; for treating Guan (urinary retention), penetrate from the middle to the lower; for treating both Guan and Ge, penetrate from the middle to both upper and lower.
Discussion on the Treatment Methods of Jin Tui Huanglian Tang (Advance and Retreat Coptis Decoction) and Shenqi Wan (Kidney Qi Pill)
Huanglian Tang is a formula by Zhang Zhongjing for treating Shang Han (Cold Damage). In Shang Han, if there is heat in the chest, pathogenic factors in the stomach, abdominal pain, and desire to vomit, Huanglian Tang is the primary prescription. Because pathogenic factors in the stomach obstruct the mechanism of Yin-Yang ascent and descent, preventing them from interacting in the Central Earth, Yin cannot ascend and stagnates alone below causing lower cold; Yang cannot descend and governs alone above causing chest heat and vomiting. This decoction regulates Yin and Yang ascent and descent, which is correct.
However, in patients with dampness who were incorrectly purged, resulting in a tongue coating resembling fetal membrane, with Heat in the Dantian and Cold in the chest, this same formula is used. Why? Shang Han is divided into Exterior, Interior, and Middle methods. When Exterior and Interior pathogens are both excessive, harmonization from the Middle is required. Hence, Xiaochaihu Tang (Minor Bupleurum Decoction) uses the Harmonizing Method, with Renshen, Gancao, Banxia, Shengjiang, and Dazao supporting the Stomach Middle, adding only Chaihu to penetrate the Exterior and Huangqin to penetrate the Interior. It allows the ascending Stomach Qi to carry Chaihu out to the Exterior, and the descending Stomach Qi to carry Huangqin into the Interior. One harmonization eliminates both Exterior and Interior pathogens. Any remaining pathogens are treated subsequently without conflict. As for pathogens in the Dantian and Chest, they are located Up and Down, not Exterior and Interior. Thus, Chaihu Tang is changed to Huanglian Tang to harmonize Up and Down: Guizhi replaces Chaihu, Huanglian replaces Huangqin, and Ganjiang replaces Shengjiang. This allows Stomach Qi to distribute up and down, treating both Upper Heat/Lower Cold and Upper Cold/Lower Heat.
For Exterior-Interior pathogens, use Chaihu and Huangqin; for Up-Down pathogens, use Guizhi and Huanglian. For Exterior-Interior pathogens, use the acridity of Shengjiang to disperse; for Up-Down pathogens, use the pungency of Ganjiang to open. Zhang Zhongjing’s sacred method is evident. As previously stated, seek in the Middle, grasp the pivot, gradually penetrate Up and Down, waiting for Ying Qi to pass first and Wei Qi to follow, adjusting accordingly.
Ge manifests as vomiting and reflux; advancing with this formula is appropriate. Since Taiyang governs opening, if Taiyang does not open, the chest becomes obstructed, food cannot enter, or if it enters, it comes back out. Guizhi is a Taiyang channel herb that harmonizes Ying and Wei and promotes Yang pathways, thus capable of opening. However, if the Fire of Jue Yang from the Five Emotions ascends, Guizhi must not be used. Using it would be like adding fire to fire, causing head sweating and Yang collapse.
For Guan manifesting as urinary retention, the retreat method penetrates into the Yin aspect via Stomach Qi; Guizhi is not taken. But if the gate of the Stomach is closed, and Shaoyin governs closing, if Shaoyin Qi does not ascend, the Stomach gate will not open. The *Nei Jing* often mentions this: "Kidney Qi sinks alone" and "Kidney Qi is unbalanced." True Qi in the Kidney acts like a weight and scale. With both weight and scale, the gate opens and closes intermittently; with weight but no scale, the gate only closes and never opens, so how can urine exit? Therefore, Shenqi Wan is essential in retreating Guan. When Kidney Qi interacts with the Stomach, the gate opens; when it interacts with the Heart, Jue Yang Fire subdues downward. There are times when it must be used.
Zhang Jingyue stated: The syndrome of Guan Ge in the *Nei Jing* originally referred to pulse morphology to illustrate the critical danger of Yin-Yang separation. Since Bian Que described Yu Yi and Fu based on Cun and Chi positions, interpreting Guan Ge by these positions already lost the original meaning of the classic. Zhang Zhongjing also said Guan is at Chi and Ge is at Cun. The *Nei Jing* states the Renying pulse is four times larger than the Cunkou; "four times" does not refer to Cun/Chi positions. Later, Zhu Danxi said this syndrome involves Cold Above and Heat Below, with both Cun pulses exceeding four times, suggesting emesis to lift horizontal obstruction. If both Cun pulses are four times larger, how can it be Cold Above? Moreover, such a large pulse is floating and rootless, indicating obvious deficiency; how can emesis be applied? This error upon error is severe.
In the *Nei Jing*, Guan Ge uses the Renying pulse to inspect Six Fu Yang and the Cunkou pulse to inspect Five Zang Yin. Renying pulse four times larger indicates isolated Yang of the Yangming channel, Water failing to control Fire, hence Ge Yang (Yin rejecting Yang). Cunkou pulse four times larger indicates Yuan Yin of the Taiyin channel lacking mastery, Qi failing to refine into Essence, hence Guan Yin (Yang obstructing Yin). If both Renying and Cunkou pulses are four times larger, large and rapid, it means Yang Qi does not store, so there is no Yang in Yin; Yin Qi does not ascend, so there is no Yin in Yang. Yin and Yang separate, hence Guan Ge.
The *Mai Du Pian* states: Excessive Yin Qi prevents Yang Qi from nourishing, hence Guan; excessive Yang Qi prevents Yin Qi from nourishing, hence Ge. Both excessive and unable to mutually nourish is Guan Ge. Patients die before their term. This shows Yang disease extremities in Yang aspects, Yin disease extremities in Yin aspects. Generally, Yang excess seems to require draining, but if Yin signs appear in the Yin aspect, draining is contraindicated; Yin extremity seems to require tonifying, but if Yang signs appear in the Yang aspect, tonifying is contraindicated. At this stage, Yang is Yang, Yin is Yin, upper and lower are blocked, neither side can be attended to, tonification and drainage are impossible, only death remains.
This differs greatly from True Cold False Heat or False Cold True Heat syndromes. Such cases generally result from alcohol and sexual activity injuring the Kidney, and emotional desires injuring Essence, causing Yang to lose its residence. Thus, the pulse is deep with exposed Qi, extremely hyperactive. True Yin is exhausted, the Root Sea has no foundation, representing extreme hyperactivity and regret, the most critical danger.
However, regarding Guan Ge diagnosis, later generations failed to inspect the Renying pulse, considering only the Cunkou as the gathering of all pulses. Wherever the pulse appears at Renying, it must appear at Cunkou. If the pulse is string-like and large to the extreme, exceeding four times, large and rapid, it is the Guan Ge pulse, and must not be mistaken for a Fire syndrome.
Generally, this syndrome lacks excess pathogenic fever, cough, or hemoptysis, which distinguishes it. However, it is common among the wealthy and obese individuals. The cause is indulgence in beauty and mid-life alcohol and sexual excess. Although seemingly different from Lao Sun (Consumption) syndrome, it is essentially an alias of it.
Therefore, the Guan Ge pulse must be string-like and large to the extreme. String-like indicates Middle Deficiency; floating and large indicates Yin Deficiency. This is a pulse of massive Kidney Water depletion, having Yang but no Yin. Treatment should primarily focus on vigorously tonifying True Yin. However, one must also differentiate Cold and Heat within Deficiency, and Yin and Yang within Yin, treating separately.