关格一病，《内经》未言其证为何，《平脉法》始举不得小便、吐逆、食不得入，至巢氏则唯云大小便不通
而不及他证，要俱不出阴阳否绝之候。前人所说，纷纠不一，今略存之，以俟有识。盖霍乱为三焦失守之病，关
格为三焦隔塞之病，故今以关格，列于霍乱之后。若夫《难经》之言，专系脉体，自是一义，学人须分别看焉。
《内经》、《伤寒论》之异 关格之脉证不一也，而马
仲化释《内经》。谓关格之义，非隔食癃闭之证，而张介宾《类经》，直将越人、仲景之言非之。医道贵乎丸
通，若执中无权，犹执一也。故释《内经》之关格，但当言是表里阴阳否绝之候，不当与上吐下闭之关格混同
立论则可；若言上吐下闭，当称隔食癃闭，不得名为关格则不可。（《医通》）（节录）
关格之证，《内经》、《伤寒论》所指不同，《内经》所云是不治之证，《伤寒论》所云则卒暴之疾，当于
通便止呕方法随宜施治可也。（《轨范》）
病由阴阳不和（三焦约）关格者，二便俱不通也。大便不通，谓之内关；小便不通，谓之外格；二便俱
不通，为关格也。由阴阳气不和，荣卫不通故也。阴气太盛，阳气不能荣之，曰内关。阳气太盛，阴气不得荣
之，曰外格。阴阳俱盛，不得相荣，曰关格。关格则阴阳气否，结于腹内胀满，气不行于大小肠，故关格而大小
便不通也。又风邪在三焦，三焦约者则小肠痛内闭，大小便不通，日不得前后而手足寒者，为三阴俱逆，三日死
也（按∶《灵枢·四时气篇》曰∶小腹痛肿，不得小便，邪在三焦约）。诊其脉来浮牢且滑直者，不得大小便也。
（《病源论》）
四明陈氏曰∶腑有邪则阳脉盛，脏有邪则阴脉盛。阴脉盛者阴气关于下，阳脉盛者阳气格于上，然而未至于
死。阴阳俱盛则既关且格，格则食不下，关则二阴闭，不得大小便而死矣。若脏腑气和而相荣，阴不复，阳不溢，
何关格之有。（《统旨》）（按∶此说亦出《医统》。）
《内经》云∶人迎脉四盛以上为格阳，寸口脉四盛以上为关阴。夫脉至四盛以上亦太盛矣，阳太盛则阴不
能荣，阴太盛则阳不能和，阴阳阻绝，天地不交而成否矣。夫饮食虽
运夫阳，而无阴则不能下，故格则吐逆者，阳独盛于上也。便液虽生乎阴，而无阳则不能通，故关则不得小便
者，阴独盛于下也。而云岐子乃谓阳反在下，阴反在上，岂通论哉。若阳果在下，阴得阳而和，小便且通矣，
阴何由而关耶。阴果在上，阳得阴而济，饮食自下矣，阳何为而格耶。（《汇论》）（按∶《纲目》载洁古及
云岐子说，以关格为上寒下热。马氏此辨，极为明 。盖病有上热下寒而无上寒下热。《金匮辑义》湿家条详
论之。但《灵·刺节真邪论》有云上寒下热，先刺项太阳，是言经络病，非言病于里者，难以为征矣。故洁古
父子说，今不敢录入。又《统旨》举陈氏及洁古说曰∶其说虽相反，要之皆病机之所有也。是骑墙之见，今亦不
从。）
关格证在《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，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。凡见此者，总由酒色伤肾，情欲伤精，以致阳不守舍，故脉浮气露，亢极如此。
此则真阴败竭，元海无根，是诚亢龙有悔之象，最危之候也。（《景岳》）
关格，即《内经》三焦约病也。约者不行之谓，谓三焦之气不得通行也。惟三焦之气不行，故上而吐逆曰
格，下而不得大小便曰关。（《尊生书》）
脉候《内经》以人迎、寸口并诊关格，今后世诊法，则但取寸口而不察人迎，似于法有未尽。然寸口
为脉之大会，而脉见于彼，未有不见于此者。所以但察气口，则人迎
之脉亦可概见。故凡见寸口弦大至极，甚至四倍以上且大且数者，便是关格之脉，不得误认为火证。余尝诊此
数人，察其脉则如弦如革，洪大异常，故云四倍。察其证，则脉动身亦动，凡乳下之虚里，脐旁之动气，无不舂
舂然、振振然与脉俱应者。察其形气，则上有微喘而动作则喘甚，肢体无力而寤寐多慌张。谓其为虚损，则本
无咳嗽失血等证，谓其为痰火，则又无实邪发热等证，此关格之所以异也。然惟富贵之人，及形体丰肥者，多有
此证。求其所因，则无非耽嗜少艾，中年酒色所致。是虽与劳损证若有不同，而实即劳损之别名也，此老成之人
所以当知慎也。（《景岳》）
关格之脉，必弦大至极，夫弦者为中虚，浮大者为肾虚，此肾水大亏，有阳无阴之脉也。治此者，宜以峻
补真阴为主。然又当察其虚中之寒热，阴中之阴阳，分别处治，斯尽善也，（同上）
证状诸说 姚氏云∶风寒冷气入腹，忽痛坚急如吹状，大小便不通，或小腹有气结，如升大胀起，名
为关格病。（《肘后》）（从《医方类聚》录）
戴云∶关格者，谓膈中觉有所碍，欲升不升，欲降不降，欲食不食，此谓气之横格也。（《钩玄》）
阴阳易位，病名关格，多不可治。若邪气留着而致者。犹可治之。（《医通》）
关格不通，不得尿，头无汗者，可治；有汗者死。（同上）
关格若头汗者（阳脱）死，脉细涩者（知阴亦竭）亦死。（《医碥》）
至于寻常腹痛，二便不通而呕吐，其脉沉静不紧盛倍大者，非关格也，乃痰食之证，宜二陈汤加白芥子、
山楂、枳
实、青皮治之。（《汇补》）（按∶寻常二便不通，自有专门，宜参。）
补泻两难 本经《脉度篇》所云，阴气太盛，则阳气不能荣也，故曰关，阳气太盛，则阴气弗能荣也，
故曰格，阴阳俱盛，不能相荣，故曰关格，关格者，不得尽期而死，此举脉证而兼言之也。若以脉言，则如前之
四倍者是也。若以证言，则又有阴阳俱盛者，以阳病极于阳分，而阴病极于阴分也。凡阳盛于阳者，若乎当泻，
而阴分见阴，又不可泻。阴极于阴者，若乎当补，而阳分见阳，又不可补。病若此者，阳自阳而阳中无阴，阴自
阴而阴中无阳，上下否隔，两顾弗能，补之不可，泻之又不可，是亦关格之证也，有死而已。此与真寒假热、真
热假寒之证大有不同，学人当辨其疑似。（《景岳》）
热剂从治 人有一时关格，大小便闭结不通，渴饮凉水，少顷即吐，又饮之又吐，面赤唇焦，粒米不能
下胃，饮一杯吐出杯半，脉亦沉伏。人以为脉绝也，谁知是格阳不宣，肾经寒邪太盛之故乎。夫肾属少阴，喜
温而不喜寒也。寒邪入肾，则阳无所附，阳欲杜阴而不能，阴且格阳而愈胜。于是阳不散居于下焦，而尽逆冲于上
焦，咽喉之间，难于容物而作吐矣。夫阳宜阴折，热宜寒折，似乎阳热在上，宜用阴寒之药以治之。然而阳热在上，
而下正阴寒也。用阴寒以折阴寒，正投其所恶也，不特无功而反有大害。盖上假热而下真寒，非用真热假寒之法
从治之，断不能顺其性而开其关也。方用白通汤治之，方中原是大热之味，得人尿、猪胆以乱之，则下咽觉寒，而
入腹正热，阳可重回而阴可立散，自然脉通而关启矣。（《辨证录》）
治宜开通 凡治关格病，不知批 导窍，但冀止呕利溲，
亟治其标，技穷力竭，无益反损，医之罪也。（《法律》）
此证危急，法难缓治，宜先投辛香通窍下降之药以治其上，次用苦寒利气下泄之药以通二便（按∶沈氏袭
洁古之谬，故用苦寒）。盖证既危急，纵有里虚，亦宜通后再补也。（《尊生书》）
用吐之谬 丹溪书云∶必用吐，提其气之横格，不必在出痰也。又云∶有痰，二陈汤吐之，吐中便有
降。中气不运者，补气药中升降。此盖窃其治小便之法，填于条下，蹈世俗之弊而不悟，悲夫。（《准绳》）
丹溪则曰此证多死，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，不必在出痰也。愚
谓两寸俱盛四倍，又安得为寒在上耶？且脉大如此，则浮豁无根，其虚可知，又堪吐乎？谬而又谬，莫此为甚
矣。（《景岳》）
疏利方法《集验》疗关格之病，肠中转痛，不得大小便，一日一夜不瘥欲死方。
芒硝三两，纸三重裹，于炭火内烧令沸，安一升水中（按∶今《肘后》作汤中），尽服之。当先饮温汤一
二升以来，吐出乃饮芒消汁也。（《肘后》同）（《外台》）（按∶今《肘后》系《医方类聚》所收。）
《广利方》关格不通，胞胀妨闷，大小便不通方。
冬葵子（三大合绵裹碎） 滑石（十二分碎） 芒硝（十分汤成下）
切，以水二大升，煎取八大合，去滓空腹，分温再服，服别如人行四五里，忌肉面。（《医心》）《圣济》
名芒硝汤。
奉职赵令仪妻，忽吐逆大小便不通，烦乱，四肢渐冷，无脉，凡一日半。与大承气汤一剂，至夜半，渐得大
便通，脉渐生，翌日乃安。此关格之病，极为难治，兆所见者，惟
此一人。（《鸡峰》）
加味麻仁丸（《会编》），治关格，大小便不通。
大黄（一两） 白芍药 浓朴（姜汁炒） 当归 杏仁（去皮尖） 麻仁 槟榔 南木香 枳壳（各五钱）
麝香（少许）
上为末，蜜丸，熟水下。（《准绳》）（按∶此盖云岐子方。）
通壅诸方 孙真人治大小便不通，关格不利，烧大皂荚细研，粥饮下三钱，立通。（《本草》）《准
绳》引《会编》名皂荚散。
人参散，治胃虚津枯，关格吐逆。
人参（五钱至一两） 麝（半分至一分） 冰脑（三厘至半分）
为散，水煎和滓，分二三次温服。（《准绳》作右末，甘草汤调服。）此云岐子治噎膈胃反关格不通九方
之一，用独参汤峻补其胃，稍加脑、麝以发越其气，得补中寓泻之至诀。若瘦人津枯不能出纳而大便秘结者，即
以此方去脑、麝，加芦根汁、竹茹，未尝不为合辙也。（《医通》）
既济丸，治关格，脉沉细，手足厥冷。
熟附子（一两，《准绳》童便浸） 人参（三两） 麝香（少许为衣）
为细末，陈米饮糊丸，梧子大，每服十丸至三十丸，米饮下。此云岐子第三方，用参、附加麝，单刀直入，
以破中下二焦之结，药虽峻而用法最缓，不可不详此义，而擅改作汤也。
调停方 进退黄连汤方，格则吐逆，进而用此方为宜。关则不得小便，退之之法，从胃气以透入阴分，
桂枝亦在所不取。（节录）
黄连（姜汁炒） 干姜（炮） 人参（人乳拌蒸一钱五分） 桂枝（一钱） 半夏（姜制一钱五分） 大枣（二枚）
进法用本方七味，俱不制，水三茶盏，煎一半，温服。退法不用桂枝，黄连减半。但空心朝服八味丸三钱，
半饥服煎剂耳。（《法律》）
外治法（宜参小便不通外治诸方）葛氏疗卒关格，大小便并不通，支满欲死，二三日则杀人方。
以苦酒和硝，涂腹上，干复易。（《肘后》）（《外台》作盐，以苦酒和，涂脐中，干又易之。）
《短剧》疗小便不通及关格方，取生土瓜根，捣取汁，以少水解之筒中，吹下部，即通秘。（同上）
灸法 治关格证，吐逆而小便不利，急宜先灸气海、天枢等穴各三七壮，其吐必止，然后以益元散等
药，以利小便。（《正传》）
关格这一病证，《内经》中未明确说明其具体症状表现，《平脉法》才开始列举出小便不通、呕吐逆气、饮食无法入口等症状，到了巢元方《诸病源候论》则只说大小便不通，而不及其它症状，总之都不超出阴阳隔绝断绝的征候。前人所说的说法，纷乱不一，现在略作保留，以等待有见识的人来评判。大概霍乱是三焦功能失守的病，关格是三焦阻隔闭塞的病，所以现在将关格列在霍乱之后。至于《难经》中的论述，专门涉及脉象形态，自成一义，学习的人必须分别看待。
《内经》与《伤寒论》观点的差异：关格的脉证并不统一，马仲化在解释《内经》时认为，关格的含义，并非指隔食（吞咽困难）和癃闭（小便不通）这类病症，而张介宾在《类经》中，直接指责越人（扁鹊）和张仲景的说法是错误的。医学之道贵在圆通灵活，如果固执不知变通，就如同拘泥于一点一样。所以解释《内经》中的关格，应当说是表里阴阳隔绝断绝的征候，不应当把上面呕吐下面闭塞的关格混同在一起讨论；如果说上面呕吐下面闭塞，应该称为隔食癃闭，不能称之为关格，这种说法是不对的。（摘自《医宗必读·医通》）
关格的证候，《内经》和《伤寒论》所指不同，《内经》所说的是不治之症，《伤寒论》所说则是突发暴烈的疾病，应当根据通便止呕的方法随宜施治即可。（摘自《医门法律·轨范》）
病因在于阴阳不和（三焦约束）：所谓关格，就是大小便都不通。大便不通，称为内关；小便不通，称为外格；大小便都不通，称为关格。这是由于阴阳之气不和，营卫之气不通畅的缘故。阴气太盛，阳气不能滋养它，叫做内关。阳气太盛，阴气不能滋养它，叫做外格。阴阳都太盛，不能互相滋养，叫做关格。关格导致阴阳之气隔绝，结聚在腹内胀满，气不行走于大小肠，所以关格而大小便不通。另外风邪在三焦，三焦受约束则小肠痛且内部闭塞，大小便不通，一天之内不能前后通畅且手足寒冷的，属于三阴经气逆乱，三天后会死亡（按：《灵枢·四时气篇》说：小腹痛肿，不能小便，邪气在三焦约束）。诊察脉象，脉来浮牢且滑直的，是大小便不通的症状。（摘自《诸病源候论》）
四明陈氏说：腑有邪气则阳脉盛，脏有邪气则阴脉盛。阴脉盛者，阴气关于下部；阳脉盛者，阳气格于上部，然而这还不至于死。如果阴阳都盛，则既关且格，格则食物下不去，关则二阴闭塞，大小便不通而死。如果脏腑之气调和而互相滋养，阴不偏盛，阳不溢散，哪里会有关格呢？（摘自《医统正脉全书·统旨》）（按：此说也出自《医统》。）
《内经》说：人迎脉盛大超过正常四倍以上为格阳，寸口脉盛大超过正常四倍以上为关阴。脉象达到四倍以上也太盛了，阳太盛则阴不能滋养，阴太盛则阳不能调和，阴阳阻绝，天地不交泰而成否塞之局。饮食虽然依靠阳气运化，但没有阴气则不能下行，所以格阳则呕吐逆气，是因为阳气独盛于上。便液虽然生于阴，但没有阳气则不能通畅，所以关阴则小便不通，是因为阴气独盛于下。而云岐子却说阳反在下，阴反在上，这难道是通论吗？如果阳真的在下，阴得到阳的温煦而调和，小便就会通畅，阴怎么会关呢？如果阴真的在上，阳得到阴的滋润而济助，饮食自然下行，阳怎么会格呢？（摘自《古今医统大全·汇论》）（按：《本草纲目》记载了洁古及云岐子的说法，认为关格是上寒下热。马氏的这种辨析，非常明白清晰。因为病有上热下寒而无上寒下热。《金匮辑义》湿家条详细论述了这一点。但《灵枢·刺节真邪论》中有“上寒下热”的说法，是先刺项部太阳经，这是讲经络病，不是讲内脏病，难以作为证据。所以洁古父子的说法，现在不敢录入。另外《统旨》列举了陈氏及洁古的说法说：他们的说法虽然相反，总之都是病机可能存在的。这是骑墙的观点，现在也不采纳。）
关格证在《内经》中，本是以人迎脉观察六腑之阳，以寸口脉观察五脏之阴。人迎脉盛至四倍以上，这是阳明经孤阳独见，水不济火，所以叫格阳。格阳，就是阴格拒于阳。气口（寸口）脉盛至四倍以上，这是太阴经元阴无主，气不归精，所以叫关阴。关阴，就是阳关于阴。如果人迎和寸口都盛至四倍以上，而且大而且数，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。凡是见到这种情况，总归是由于酒色伤肾，情欲伤精，导致阳不守舍，所以脉浮气露，亢极如此。这是真阴败竭，元海无根，确实是亢龙有悔的景象，是最危险的征候。（摘自《景岳全书》）
关格，就是《内经》中三焦约束的病。约就是不通行的意思，指三焦之气不得通行。只有三焦之气不行，所以上面呕吐逆气叫格，下面大小便不通叫关。（摘自《尊生八书》）
脉象候诊：《内经》用人迎、寸口并诊来判断关格，但后世的诊法，只取寸口而不察人迎，似乎对法度有所未尽。然而寸口是脉之大会，脉象在那里出现，没有不在这里出现的。所以只要察气口，人迎的脉也可以概见。所以凡是见到寸口弦大至极，甚至四倍以上且大且数的，就是关格的脉，不要误认为是火证。我曾经诊治过几个人，察其脉象如弦如革，洪大异常，所以说四倍。察其证候，脉动身体也动，凡是乳下的虚里穴，脐旁的动气，无不跳动剧烈、振颤地与脉搏相应。察其形体气息，上面有轻微气喘而动作则喘甚，肢体无力且醒睡多慌张。说是虚损，则原本没有咳嗽失血等证；说是痰火，则又没有实邪发热等证，这就是关格的不同之处。然而只有富贵之人，以及形体丰肥者，多有此证。探求其原因，无非是沉溺于少艾（年轻女子），中年酒色所致。这虽然与劳损证似乎不同，而实际上就是劳损的别名，这是老成之人应当知道谨慎的。（摘自《景岳全书》）
关格的脉，必定弦大至极，弦脉代表中虚，浮大脉代表肾虚，这是肾水大亏，有阳无阴的脉象。治疗此证，应当以峻补真阴为主。然而又应当察其虚中的寒热，阴中的阴阳，分别处理治疗，这才是尽善尽美。（同上）
症状诸说：姚氏说：风寒冷气入腹，忽然疼痛坚硬紧急像吹起的气囊状，大小便不通，或者小腹有气结聚，像升大的胀起，名为关格病。（摘自《肘后备急方》，从《医方类聚》录）
戴云说：关格，是指膈中觉得有什么阻碍，想升不能升，想降不能降，想吃不能吃，这叫气之横格。（摘自《医学钩玄》）
阴阳易位，病名关格，大多不可治。如果是邪气留着导致的，还可以治。（摘自《医宗必读·医通》）
关格不通，不得尿，头无汗的，可治；有汗的，死。（同上）
关格如果头出汗的（阳气脱失）死，脉细涩的（知道阴也竭尽）也死。（摘自《医碥》）
至于寻常腹痛，大小便不通而呕吐，其脉沉静不紧盛倍大的，不是关格，乃是痰食之证，宜用二陈汤加白芥子、山楂、枳实、青皮治疗。（摘自《杂病源流犀烛·汇补》）（按：寻常大小便不通，自有专门治法，宜参考。）
补泻两难：本经《脉度篇》所说，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；阴阳俱盛，不能相互荣养，所以叫关格。关格者，不能尽其天年而死，这是举脉证兼而言之。如果单说脉，就像前面说的四倍那样。如果单说证，又有阴阳俱盛的，是因为阳病极于阳分，而阴病极于阴分。凡阳盛于阳分的，好像应当泻，而阴分见阴，又不可泻。阴极于阴的，好像应当补，而阳分见阳，又不可补。病像这样的，阳自阳而阳中无阴，阴自阴而阴中无阳，上下隔绝，两顾不能，补不可，泻又不可，这也是关格的证候，只有死而已。这与真寒假热、真热假寒的证候大有不同，学习的人应当辨别其疑似。（摘自《景岳全书》）
热剂从治：有人一时关格，大小便闭结不通，口渴喝凉水，一会儿就吐出来，再喝又吐，面赤唇焦，粒米不能下胃，喝一杯吐出半杯，脉也沉伏。人们以为是脉绝，谁知道这是格阳不宣，肾经寒邪太盛的缘故呢？肾属少阴，喜温而不喜寒。寒邪入肾，则阳无所依附，阳想杜绝阴而不能，阴反而格拒阳而更胜。于是阳不散居于下焦，而尽逆冲于上焦，咽喉之间，难于容纳物而作吐。夫阳宜阴折，热宜寒折，似乎阳热在上，宜用阴寒之药来治。然而阳热在上，而下正阴寒。用阴寒来折阴寒，正是投其所恶，不仅无功反而有大害。因为是上假热而下真寒，非用真热假寒之法从治，断不能顺其性而开其关。方用白通汤治疗，方中原是大热之味，得人尿、猪胆来扰乱它，则下咽觉寒，而入腹正热，阳可重回而阴可立散，自然脉通而关启了。（摘自《辨证录》）
治宜开通：凡是治疗关格病，不知道开通窍道，只希望止呕利溲，急于治标，技穷力竭，无益反损，这是医生的罪过。（摘自《医门法律》）
此证危急，法难缓治，宜先投辛香通窍下降之药以治其上，次用苦寒利气下泄之药以通二便（按：沈氏袭用洁古的错误，所以用苦寒）。因为证既危急，纵有里虚，也宜通后再补。（摘自《尊生八书》）
用吐法的谬误：丹溪书上说：必用吐法，提其气之横格，不必在于出痰。又说：有痰，用二陈汤吐之，吐中便有降。中气不运者，在补气药中升降。这大概是窃取他治疗小便的方法，填在条文下，蹈世俗之弊而不悟，可悲啊。（摘自《医学准绳六要》）
丹溪则说此证多死，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，不必在于出痰。我认为两寸俱盛四倍，又怎么能说是寒在上呢？且脉大如此，则浮豁无根，其虚可知，又堪吐乎？谬上加谬，没有比这更严重的了。（摘自《景岳全书》）
疏利方法：《集验方》治疗关格病，肠中转痛，不得大小便，一日一夜不好欲死的方子。
芒硝三两，纸三重包裹，在炭火内烧令沸，放入一升水中（按：今本《肘后方》作汤中），全部服下。应当先饮温汤一二升左右，吐出后再饮芒硝汁。（《肘后方》相同）（摘自《外台秘要》）（按：今本《肘后方》系《医方类聚》所收。）
《广利方》关格不通，胞胀妨闷，大小便不通方。
冬葵子（三大合绵裹碎） 滑石（十二分碎） 芒硝（十分汤成下）
切碎，用水二大升，煎取八大合，去滓空腹，分两次温服，服药后如人行走四五里的时间，忌吃肉面。（摘自《医心方》《圣济总录》名芒硝汤。）
奉职赵令仪的妻子，忽然呕吐逆气大小便不通，烦乱，四肢渐冷，无脉，共一天半。给予大承气汤一剂，到半夜，渐渐得大便通，脉渐生，第二天才安。这是关格之病，极为难治，兆所见到的，只有此人。（摘自《鸡峰普济方》）
加味麻仁丸（《会编》），治关格，大小便不通。
大黄（一两） 白芍药 浓朴（姜汁炒） 当归 杏仁（去皮尖） 麻仁 槟榔 南木香 枳壳（各五钱）
麝香（少许）
上为末，蜜丸，熟水下。（摘自《医学准绳六要》）（按：这大概是云岐子的方子。）
通壅诸方：孙真人治疗大小便不通，关格不利，烧大皂荚细研，粥饮下三钱，立通。（摘自《本草纲目》《准绳》引《会编》名皂荚散。）
人参散，治胃虚津枯，关格吐逆。
人参（五钱至一两） 麝（半分至一分） 冰脑（三厘至半分）
为散，水煎和滓，分二三次温服。（《准绳》作右末，甘草汤调服。）这是云岐子治疗噎膈胃反关格不通九方之一，用独参汤峻补其胃，稍加脑、麝以发越其气，得补中寓泻的至诀。如果瘦人津枯不能出纳而大便秘结者，就用此方去脑、麝，加芦根汁、竹茹，也未尝不合辙。（摘自《医宗必读·医通》）
既济丸，治关格，脉沉细，手足厥冷。
熟附子（一两，《准绳》童便浸） 人参（三两） 麝香（少许为衣）
为细末，陈米饮糊丸，梧子大，每服十丸至三十丸，米饮下。这是云岐子第三方，用参、附加麝，单刀直入，以破中下二焦之结，药虽峻而用法最缓，不可不详此义，而擅改作汤也。
调停方：进退黄连汤方，格则吐逆，进而用此方为宜。关则不得小便，退之之法，从胃气以透入阴分，桂枝亦在所不取。（节录）
黄连（姜汁炒） 干姜（炮） 人参（人乳拌蒸一钱五分） 桂枝（一钱） 半夏（姜制一钱五分） 大枣（二枚）
进法用本方七味，俱不制，水三茶盏，煎一半，温服。退法不用桂枝，黄连减半。但空心朝服八味丸三钱，半饥服煎剂耳。（摘自《医门法律》）
外治法（宜参小便不通外治诸方）：葛氏治疗卒关格，大小便并不通，支满欲死，二三日则杀人方。
以苦酒和硝，涂腹上，干了再换。（《肘后方》）（《外台》作盐，以苦酒和，涂脐中，干了再换。）
《短剧方》治疗小便不通及关格方，取生土瓜根，捣取汁，以少量水解之筒中，吹下部，即通秘。（同上）
灸法：治关格证，吐逆而小便不利，急宜先灸气海、天枢等穴各三七壮，其吐必止，然后以益元散等药，以利小便。（摘自《丹溪心法·正传》）
Guan-Ge (Obstruction and Rejection) is a disease. The *Neijing* (Classic of Internal Medicine) does not explicitly state its symptoms. The *Ping Mai Fa* (Method of Pulse Diagnosis) first listed symptoms such as inability to urinate, vomiting and regurgitation, and inability to ingest food. Later, Chao Yuanfang in his work only mentioned the obstruction of both bowel and bladder movements, omitting other symptoms. In essence, all these descriptions fall within the pattern of Yin-Yang isolation and interruption. The explanations given by predecessors are diverse and inconsistent; I retain them briefly here for scholars with insight to evaluate. Generally speaking, Huoluan (Cholera-like disorder) is a disease of the Sanjiao (Triple Burner) losing its control, whereas Guan-Ge is a disease of Sanjiao blockage and obstruction. Therefore, Guan-Ge is listed after Huoluan in this text. As for the statements in the *Nanjing* (Classic of Difficult Issues), they specifically refer to pulse morphology, representing a distinct perspective; students must distinguish between them.
**Differences between the *Neijing* and *Shanghan Lun*:** The pulse and symptom manifestations of Guan-Ge vary. Ma Zhonghua, in his commentary on the *Neijing*, argued that the meaning of Guan-Ge does not refer to conditions like Geshi (food retention/dysphagia) or Longbi (urinary retention). Zhang Jiebin, in his *Leijing* (Classified Classic), directly criticized the views of Yue Ren (Bian Que) and Zhang Zhongjing. Medical practice values flexibility and holistic understanding; rigidity without adaptability is akin to sticking to one narrow point. Therefore, when interpreting Guan-Ge in the *Neijing*, it should be described as a sign of isolation and interruption of Yin and Yang in the exterior and interior. It should not be conflated with the Guan-Ge characterized by upper vomiting and lower obstruction. Conversely, claiming that upper vomiting and lower obstruction should be termed Geshi and Longbi, and thus cannot be called Guan-Ge, is incorrect. (Excerpted from *Yitong*)
The manifestations of Guan-Ge differ between the *Neijing* and the *Shanghan Lun*. The *Neijing* refers to it as an incurable condition, while the *Shanghan Lun* describes it as a sudden and violent illness. Treatment should be applied flexibly according to methods that promote bowel movement and stop vomiting. (Excerpted from *Guifan*)
**Etiology: Yin-Yang Disharmony (Sanjiao Constraint):** Guan-Ge refers to the simultaneous obstruction of both bowel and bladder movements. Obstruction of stool is called Neiguan (Internal Closure); obstruction of urine is called Waige (External Rejection); simultaneous obstruction of both is called Guan-Ge. This arises from the disharmony of Yin and Qi, leading to the blockage of Ying (Nutrient) and Wei (Defensive) Qi. When Yin Qi is excessively strong, Yang Qi cannot nourish it, termed Neiguan. When Yang Qi is excessively strong, Yin Qi cannot nourish it, termed Waige. When both Yin and Yang are excessively strong and fail to mutually nourish each other, it is termed Guan-Ge. Guan-Ge results in the stagnation of Yin and Yang Qi, causing abdominal distension. Qi fails to circulate through the large and small intestines, leading to the obstruction of both bowels and bladder. Additionally, if Wind-Evil affects the Sanjiao, causing Sanjiao constraint, there may be pain in the small intestine with internal closure, obstruction of both bowels and bladder, inability to pass urine or stool for a day, and cold extremities. This indicates reversal of the Three Yin meridians and is fatal within three days. (Note: The *Lingshu · Four Seasons Qi Chapter* states: "Pain and swelling in the lower abdomen, inability to urinate, evil located in the Sanjiao constraint.") Palpating the pulse, if it comes floating, firm, slippery, and straight, it indicates obstruction of both bowels and bladder. (Excerpted from *Bingyuan Lun*)
Chen Si Ming said: When Fu organs have evil, the Yang pulse becomes vigorous; when Zang organs have evil, the Yin pulse becomes vigorous. Vigorous Yin pulse indicates Yin Qi constrained at the lower part; vigorous Yang pulse indicates Yang Qi rejected at the upper part. However, this has not yet reached death. If both Yin and Yang pulses are vigorous, it is both Guan and Ge. Ge means food cannot go down; Guan means the two orifices are closed, leading to death due to inability to pass urine and stool. If Zang and Fu Qi are harmonious and mutually nourishing, with Yin not excessive and Yang not overflowing, how could Guan-Ge occur? (Excerpted from *Tongzhi*) (Note: This view also appears in *Yitong*.)
The *Neijing* states: A Renying (Carotid) pulse exceeding four times the normal size indicates Ge Yang (Rejection of Yang); a Cunkou (Radial) pulse exceeding four times the normal size indicates Guan Yin (Closure of Yin). A pulse reaching four times the normal size is excessively vigorous. Excessive Yang prevents Yin from nourishing; excessive Yin prevents Yang from harmonizing. Yin and Yang become blocked, Heaven and Earth do not interact, resulting in Pi (Stagnation). Although dietary transport relies on Yang, without Yin it cannot descend; thus, Ge manifests as vomiting because Yang alone is excessive at the top. Although fluid excretion originates from Yin, without Yang it cannot flow; thus, Guan manifests as inability to urinate because Yin alone is excessive at the bottom. Yun Qizi claimed that Yang is reversed to the lower part and Yin to the upper part. Is this a universal theory? If Yang were truly below, Yin would harmonize with Yang, and urination would be smooth; how could Yin be closed? If Yin were truly above, Yang would assist Yin, and food would descend; how could Yang be rejected? (Excerpted from *Huilun*) (Note: *Bencao Gangmu* records the views of Jiegu and Yun Qizi, stating Guan-Ge is Cold above and Heat below. Ma's refutation is very clear. Diseases can present as Heat above and Cold below, but not Cold above and Heat below. *Jingui Jiyi* discusses this in detail under the Dampness section. However, the *Lingshu · Ci Jie Zhen Xie Lun* mentions "Cold above, Heat below," referring to channel diseases rather than interior diseases, so it cannot serve as evidence. Thus, I dare not include the Jiegu father-son theory. Furthermore, *Tongzhi* cites Chen and Jiegu, saying their opposing views represent possible pathomechanisms. This is a fence-sitting view, which I also reject.)
In the *Neijing*, Guan-Ge is originally diagnosed by observing the Yang of the Six Fu organs via the Renying pulse and the Yin of the Five Zang organs via the Cunkou pulse. A Renying pulse exceeding four times the normal size indicates solitary Yang in the Yangming Channel, where Water fails to control Fire, hence called Ge Yang (Rejection of Yang by Yin). A Cunkou pulse exceeding four times the normal size indicates the Masterless Primordial Yin in the Taiyin Channel, where Qi fails to condense into Essence, hence called Guan Yin (Closure of Yin by Yang). If both Renying and Cunkou pulses exceed four times the normal size, are large, and rapid, it indicates Yang failing to store, leading to no Yang within Yin, and Yin failing to ascend, leading to no Yin within Yang. Yin and Yang separate, hence named Guan-Ge. All such cases result from alcohol and sexual excess damaging the Kidney, and emotional desires damaging Jing (Essence), causing Yang to lose its residence. Thus, the pulse floats and Qi reveals itself, becoming extremely hyperactive. This represents the exhaustion of True Yin and the rootlessness of the Yuan Sea, a sign of extreme danger akin to "the arrogant dragon repents." (Excerpted from *Jingyue*)
Guan-Ge is the Sanjiao constraint disease mentioned in the *Neijing*. "Constraint" means non-circulation, referring to the failure of Sanjiao Qi to move freely. Because Sanjiao Qi does not move, vomiting and regurgitation occur above (called Ge), and obstruction of both bowels and bladder occurs below (called Guan). (Excerpted from *Zunsheng Shu*)
**Pulse Diagnosis:** The *Neijing* uses both Renying and Cunkou pulses to diagnose Guan-Ge. Later diagnostic methods only use Cunkou and ignore Renying, which seems incomplete. However, Cunkou is the meeting place of all pulses; if a pulse appears there, it must appear here. Therefore, observing Cunkou allows one to infer the Renying pulse. Thus, whenever the Cunkou pulse is wiry, large to the extreme, even four times the normal size, large and rapid, it is the pulse of Guan-Ge. Do not mistake it for a Fire syndrome. I have treated several such patients. Their pulses were wiry and leathery, exceptionally large and flooding, hence described as four times normal. Their symptoms included body movement accompanying pulse movement; the Xu Li point below the breastbone and the Dong Qi point beside the navel all throbbed and trembled in sync with the pulse. Their form and Qi showed slight panting at rest, worsening with movement, limb weakness, and anxiety during sleep and wakefulness. Calling it Deficiency-Damage, there were no cough or hemoptysis; calling it Phlegm-Fire, there was no excess heat fever. This distinguishes Guan-Ge. However, this syndrome is common among the wealthy and those with robust physiques. The cause is indulgence in youth and sexual activity in middle age. Although different from typical Lao Sun (Consumption), it is essentially another name for it. Elderly and experienced physicians should be cautious. (Excerpted from *Jingyue*)
The Guan-Ge pulse is invariably wiry and extremely large. Wiry indicates Middle Jiao deficiency; floating and large indicate Kidney deficiency. This is a pulse of severe Kidney Water depletion, having Yang but lacking Yin. Treatment should focus on vigorously tonifying True Yin. However, one must also examine the Cold/Heat within the deficiency, and Yin/Yang within the Yin aspect, treating accordingly for perfection. (Ibid.)
**Symptom Descriptions:** Yao stated: Wind-Cold-Qi entering the abdomen causes sudden, hard, tight pain like an inflated bag, with obstruction of both bowels and bladder, or Qi knotting in the lower abdomen causing distension like a rising vessel. This is named Guan-Ge disease. (Excerpted from *Zhouhou*, from *Yifang Leiju*)
Dai Yun stated: Guan-Ge refers to a sensation of obstruction in the Diaphragm, where Qi wants to rise but cannot, wants to descend but cannot, wants to eat but cannot. This is called Horizontal Rejection of Qi. (Excerpted from *Gouxuan*)
When Yin and Yang reverse positions, the disease is named Guan-Ge, and is mostly incurable. If caused by lingering Evil, it may still be treatable. (Excerpted from *Yitong*)
If Guan-Ge leads to inability to urinate, and the head has no sweat, it is treatable; if there is sweat on the head, it is fatal. (Ibid.)
If Guan-Ge presents with sweating on the head (Yang collapse), it is fatal. If the pulse is fine and choppy (indicating Yin exhaustion), it is also fatal. (Excerpted from *Yibei*)
As for ordinary abdominal pain with obstruction of both bowels and bladder and vomiting, if the pulse is calm, not tight, and not excessively large, it is not Guan-Ge, but a Phlegm-Food retention syndrome. Treat with Erchen Tang plus Baijiezi, Shanzha, Zhishi, and Qingpi. (Excerpted from *Huibu*) (Note: Ordinary obstruction of bowels and bladder has specific treatments; consult those.)
**Difficulty of Tonification and Purging:** The *Mai Du Pian* chapter states: Excessive Yin Qi prevents Yang from nourishing, hence Guan; excessive Yang Qi prevents Yin from nourishing, hence Ge; mutual lack of nourishment due to excess in both is Guan-Ge. Guan-Ge leads to premature death. This combines pulse and symptom discussion. Regarding pulses, it refers to the four-times-normal magnitude mentioned earlier. Regarding symptoms, there are cases of mutual excess, where Yang pathology extremes in the Yang aspect and Yin pathology extremes in the Yin aspect. If Yang is excessive in the Yang aspect, it seems purgation is needed, but if Yin signs appear in the Yin aspect, purgation is contraindicated. If Yin is extreme in the Yin aspect, it seems tonification is needed, but if Yang signs appear in the Yang aspect, tonification is contraindicated. In such cases, Yang exists in Yang but lacks Yin within; Yin exists in Yin but lacks Yang within. Upper and Lower are isolated; neither side can be attended to. Tonification is impossible, purgation is impossible. This is also a Guan-Ge syndrome, leading only to death. This differs significantly from True Cold False Heat and True Heat False Cold syndromes. Students must distinguish these similarities and differences. (Excerpted from *Jingyue*)
**Treating with Hot Agents Following the Disease Nature:** Some patients experience sudden Guan-Ge, with constipation and urinary retention, thirst for cold water, but vomiting immediately after drinking, face red, lips scorched, unable to swallow rice, vomiting half a cup after drinking one. The pulse is deep and hidden. People think it is pulse extinction, but it is actually Ge Yang (Rejection of Yang) due to excessive Cold-Evil in the Kidney Meridian. The Kidney belongs to Shaoyin, preferring warmth and disliking cold. When Cold-Evil enters the Kidney, Yang has no attachment. Yang tries to suppress Yin but fails; Yin rejects Yang and becomes stronger. Yang, unable to reside in the Lower Jiao, rushes upward to the Upper Jiao. The throat cannot accommodate this, causing vomiting. Although Yang should be controlled by Yin and Heat by Cold, suggesting Yang-Heat above requires Yin-Cold herbs, the reality is Yang-Heat above but True Cold below. Using Yin-Cold to counteract Yin-Cold attacks what the body dislikes, causing harm. Since it is False Heat above and True Cold below, one must use True Heat with False Cold properties to follow the disease nature and open the obstruction. Use Baotong Tang. The formula contains hot herbs, but adding Human Urine and Pig Gallbladder confuses the taste, making it feel cold upon swallowing but hot in the abdomen. Yang returns, Yin disperses, pulses open, and obstruction clears. (Excerpted from *Bianzheng Lu*)
**Treatment Should Open Obstructions:** Treating Guan-Ge without opening orifices, merely hoping to stop vomiting or promote urination, focusing urgently on symptoms until exhausted, is harmful and adds damage. This is the doctor's fault. (Excerpted from *Falv*)
This syndrome is critical and cannot be treated slowly. First, administer acrid-aromatic orifice-opening and descending herbs for the upper part, then bitter-cold Qi-promoting and draining herbs for the lower part to unblock bowels and bladder. (Note: Shen copied Jiegu's error by using bitter-cold.) Since the condition is critical, even if there is Interior Deficiency, one must unblock before tonifying. (Excerpted from *Zunsheng Shu*)
**Fallacy of Using Emesis:** Danxi wrote: One must use emesis to lift the horizontal rejection of Qi, not necessarily to expel phlegm. Also: If there is phlegm, use Erchen Tang to induce vomiting; vomiting contains descending action. For Middle Qi stagnation, use ascending-descending herbs within tonics. This steals the method for treating urinary retention and applies it incorrectly, following vulgar errors without realization. Tragic. (Excerpted from *Zhunseng*)
Danxi said this syndrome often leads to death, with Cold above and Heat below, and both Cun pulses exceeding four times normal, requiring emesis to lift horizontal Qi rejection, not necessarily to expel phlegm. I argue: If both Cun pulses exceed four times normal, how can it be Cold above? Such a large pulse indicates floating, hollow, and rootless, showing obvious deficiency. Can emesis be used? This is fallacy upon fallacy, worse than any other. (Excerpted from *Jingyue*)
**Methods for Unblocking and Draining:** *Jiyan* treats Guan-Ge with intestinal twisting pain and obstruction of both bowels and bladder, dying after one day and night.
Mangxiao (Mirabilite) 3 liang, wrapped in triple-layered paper, heated in charcoal fire until boiling, placed in 1 sheng of water. Drink all. First drink 1-2 sheng of warm water, vomit, then drink the Mangxiao solution. (*Zhouhou* agrees). (*Waitai*) (Note: Current *Zhouhou* is collected in *Yifang Leiju*.)
*Guangli Fang* for Guan-Ge obstruction, bladder distension and oppression, obstruction of both bowels and bladder.
Dongkuizi (Malva Seed) 3 dahe (wrapped in silk and crushed), Huashi (Talcum) 12 fen (crushed), Mangxiao (Mirabilite) 10 fen (added when decoction is ready).
Cut, decoct in 2 da sheng of water to obtain 8 da he. Strain. Take warm on empty stomach in two doses. After taking, walk about 4-5 li. Avoid meat and wheat products. (*Yixin Fang*). *Shengji Zonglu* calls it Mangxiao Tang.
Zhongzhi Zhao Lingyi's wife suddenly had vomiting, regurgitation, and obstruction of both bowels and bladder, agitation, gradual coldness of limbs, and absence of pulse for 1.5 days. Given one dose of Dachengqi Tang. By midnight, bowel movement gradually resumed, pulse returned, and she was safe the next day. This case of Guan-Ge is extremely difficult to treat; I have seen only this one case. (*Jifeng*)
Jiawei Maren Wan (*Huibian*), treats Guan-Ge with obstruction of both bowels and bladder.
Dahuang (Rhubarb) 1 liang, Baishaoyao (White Peony Root), Nongpo (Magnolia Bark, stir-fried with ginger juice), Danggui (Angelica Sinensis), Xingren (Apricot Kernel, skin and tip removed), Maren (Hemp Seed), Binglang (Areca Nut), Nanmuxiang (Aucklandia Root), Zhike (Bitter Orange, each 5 qian), Shexiang (Musk, a little).
Grind to powder, make honey pills, take with cooked water. (*Zhunseng*) (Note: This is likely Yun Qizi's formula.)
**Formulas for Unblocking Obstructions:** Sun Simiao treats obstruction of both bowels and bladder, unfavorable Guan-Ge, by burning large Zaojiao (Gleditsia Sinensis Pod), grinding finely, and taking 3 qian with gruel. Immediate relief. (*Bencao*). *Zhunseng* cites *Huibian* naming it Zaojiao San.
Ren Shen San (Ginseng Powder), treats Stomach Deficiency and Fluid Depletion with Guan-Ge vomiting and regurgitation.
Renshen (Ginseng Root) 5 qian to 1 liang, She (Musk) 0.5-1 fen, Bingnao (Borneol) 0.3-0.5 fen.
Grind to powder. Decoct in water, mix dregs, take warm in 2-3 doses. (*Zhunseng* says grind right ingredients, mix with Licorice Decoction). This is one of Yun Qizi's nine formulas for Yige (Dysphagia), Weifan (Regurgitation), and Guan-Ge obstruction. Uses Dushen Tang (Single Ginseng Decoction) to vigorously tonify Stomach, adding Borneol and Musk to vent Qi, achieving tonification containing purgation. For thin people with Fluid Depletion unable to intake/output and constipation, remove Borneol and Musk, add Reed Rhizome Juice and Bamboo Shavings; this is also appropriate. (*Yitong*)
Jiji Wan (Both Crossing Pill), treats Guan-Ge with deep-fine pulse and cold extremities.
Shufuzi (Prepared Aconite Root) 1 liang (*Zhunseng*: soaked in child's urine), Renshen (Ginseng Root) 3 liang, Shexiang (Musk, a little as coating).
Grind to fine powder, make pills with old rice paste, size of wu zi (bayberry seed). Take 10-30 pills per dose with rice water. This is Yun Qizi's third formula. Using Ginseng, Aconite, and Musk strikes directly to break knots in Middle and Lower Jiao. Though potent, the administration is slow. One must understand this principle and not arbitrarily change it to a decoction.
**Balancing Formula:** Jin Tui Huanglian Tang (Advance-Retreat Coptis Decoction). For Ge (vomiting/regurgitation), advance with this formula. For Guan (urinary retention), retreat by guiding from Stomach Qi into Yin aspect; Guizhi (Cinnamon Twig) is excluded. (Excerpted)
Huanglian (Coptis Rhizome, stir-fried with ginger juice), Ganjiang (Dried Ginger, roasted), Renshen (Ginseng Root, steamed with human milk, 1.5 qian), Guizhi (Cinnamon Twig, 1 qian), Banxia (Pinellia Tuber, processed with ginger, 1.5 qian), Dazao (Jujube, 2 pieces).
Advance method: Use all seven ingredients unprocessed. Decoct in 3 tea cups of water to half volume. Take warm. Retreat method: Exclude Guizhi, halve Huanglian. Take 3 qian of Bawei Wan (Eight-Ingredient Pill) on an empty stomach in the morning, and the decoction when half-hungry. (*Falv*)
**External Treatments** (Consult external treatments for urinary retention): Ge Shi treats sudden Guan-Ge with obstruction of both bowels and bladder, fullness and distress nearing death, fatal in 2-3 days.
Mix Kujiu (Vinegar) and Xiaoshao (Saltpeter/Niter), apply to abdomen. Replace when dry. (*Zhouhou*). (*Waitai* says use salt mixed with vinegar, apply to umbilicus, replace when dry.)
*Duanju Fang* treats urinary retention and Guan-Ge. Take fresh Tugua Gen (Trichosanthes Root), crush to extract juice, dilute slightly with water in a tube, blow into the lower orifice. Immediately relieves constipation. (Ibid.)
**Moxibustion:** For Guan-Ge with vomiting and dysuria, urgently moxa Qihai and Tianshu points, 21-27 moxa cones each. Vomiting will stop, then use Yi Yuan San etc. to promote urination. (*Zhengchuan*)