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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.