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Zhang Yangtu suffered from Shanghan (Cold Damage) for more than eight or nine days. He experienced vomiting and regurgitation, was unable to take food, and had urinary retention with a sensation of fullness and obstruction. The physician diagnosed it as vomiting due to Stomach Heat, believing that the pathogen had transmitted to the Bladder, causing urinary obstruction. Upon examining his pulse, I observed an overflow pulse (Yi Mai) at the Cun (Inch) position extending upwards, and a covering pulse (Fu Mai) at the Chi (Cubit) position extending downwards, while the Guan (Bar) position was hidden and imperceptible. I then concluded: This is the Ge Yang Guan Yin syndrome (Exterior Grid and Interior Gate Syndrome). Yang overflows upward and cannot descend; Yin covers downward and cannot ascend. There is a pathology of Guan Ge (Grid and Gate) in the middle jiao, which is why repeated sweating failed to produce perspiration. I administered Touge San (Diaphragm-Penetrating Powder), and after three doses, the vomiting ceased, urination became smooth, and the condition resolved.

The discussion states: Someone asked, what are Ge Yang and Guan Yin? The answer is: The Nan Jing (Classic of Difficult Issues) records that movement at the Cun (Inch) position, which is anterior to the Guan (Bar), indicates the movement of Yang. The pulse should be nine fen long and floating. If it exceeds this, the method calls it "excess" (Tai Guo); if it falls short, the method calls it "deficiency" (Bu Ji). If the pulse qi enters the Chi (Cubit) position, it is called "covering" (Fu), forming the internal Guan (Gate) and external Ge (Grid) pattern, which is a pulse sign of Yin encroaching. It further states: When Yin Qi is excessively strong, Yang Qi cannot circulate, hence it is called "Guan" (Gate/Obstruction); when Yang Qi is excessively strong, Yin Qi cannot circulate, hence it is called "Ge" (Grid/Rejection). When both Yin and Yang are excessive and cannot mutually circulate, it is called "Guan Ge". Those suffering from Guan Ge often die before their natural lifespan ends. The Su Wen (Basic Questions) states: When the Ren Ying pulse (carotid artery) is four times stronger than normal, it is Ge Yang (Exterior Grid); when the Cun Kou pulse (radial artery) is four times stronger than normal, it is Guan Yin (Internal Gate). When both Ren Ying and Cun Kou pulses are four times stronger than normal, it is Guan Ge. Zhang Zhongjing stated: Pulse at the Chi position indicates Guan; pulse at the Cun position indicates Ge. Guan results in difficult urination; Ge results in vomiting and regurgitation. Furthermore, a Fu Yang pulse (dorsalis pedis artery) that is floating and choppy indicates vomiting and regurgitation with undigested food and drink due to floating; and inability to eat due to choppy quality, named Guan Ge. From this perspective, a Guan pulse that is deep, hidden, and choppy, accompanied by Fu and Yi pulses at the Cun and Chi positions, indicates Guan Ge disease. Why is this so? Heaven Qi descends, Earth Qi ascends; in the hexagrams, this is Tai (Peace), meaning openness. If Heaven Qi does not descend and Earth Qi does not ascend, in the hexagrams, this is Pi (Stagnation), meaning closure. Now, Yang does not descend, rising to the Yu Ji area to form an overflow pulse, thus the symptom is vomiting and regurgitation, named Exterior Ge; Yin cannot float upward and enter the Chi position to form a covering pulse, thus the symptom is urinary obstruction, named Internal Guan. This explains the characteristics of Guan Ge.