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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.