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(Su Wen: Chapter 6, Six Sections and Zang-Fu Manifestations; Chapter 13, Essential Refinements of the Pulse)

Therefore, when the Renying pulse (Renying, the pulse of the Foot-Yangming Stomach meridian, located beside the laryngeal prominence on the neck) is one-fold stronger than the Cunkou pulse (Cunkou, the pulse of the Hand-Taiyin Lung meridian, located at the radial artery of the wrist), the disease is in Shaoyang (Gallbladder and Sanjiao); when it is two-fold stronger, the disease is in Taiyang (Bladder and Small Intestine); when it is three-fold stronger, the disease is in Yangming (Stomach and Large Intestine); when it is four-fold or more stronger, it is termed Ge Yang (Excess Yang where Yin cannot penetrate).

(Note: Renying is the pulse of the Foot-Yangming Stomach meridian, located 1.5 cun lateral to the laryngeal prominence. "One-fold" and "two-fold" refer to one times and two times, respectively, indicating a comparison between the Renying and Cunkou pulses, where one may be larger than the other, showing differences of three or four times. The Jin Fu chapter states: "Cunkou primarily reflects internal conditions, while Renying primarily reflects external conditions. They should correspond, moving together as if drawn by a rope of equal tension. In spring and summer, Renying is slightly larger; in autumn and winter, Cunkou is slightly larger. Such a person is called a healthy individual (Ping Ren). Thus, if Renying and Cunkou show significant disparity in strength, illness is inevitable. However, Renying observes Yang; hence, one-fold excess is in Shaoyang, i.e., Gallbladder and Sanjiao; two-fold excess is in Taiyang, i.e., Bladder and Small Intestine; three-fold excess is in Yangming, i.e., Stomach and Large Intestine. Four-fold or more excess occurs because Yang pulses are excessively strong while Yin cannot penetrate, hence termed Ge Yang. This meaning is elaborated in detail in the Zhong Shi and Jin Fu chapters, see Acupuncture Category 28-29. Also, the Jing Mai chapter explains this clearly, see Disease Category 10.)

When the Cunkou pulse is one-fold stronger than the Renying pulse, the disease is in Jueyin (Liver and Pericardium); when it is two-fold stronger, the disease is in Shaoyin (Heart and Kidney); when it is three-fold stronger, the disease is in Taiyin (Spleen and Lung); when it is four-fold or more stronger, it is termed Guan Yin (Excess Yin where Yang cannot interact).

(Note: Cunkou is the pulse of the Hand-Taiyin Lung meridian. Cunkou observes Yin; hence, one-fold excess is in Jueyin, i.e., Liver and Pericardium; two-fold excess is in Shaoyin, i.e., Heart and Kidney; three-fold excess is in Taiyin, i.e., Spleen and Lung. Four-fold or more excess occurs because Yin pulses are excessively strong while Yang cannot interact, hence termed Guan Yin. The detailed meanings in Zhong Shi and Jin Fu are the same as above.)

If both Renying and Cunkou pulses are excessively strong, exceeding normal strength by four-fold or more, it is termed Guan Ge (Guan and Ge). The Guan Ge pulse is weak and degenerated; if it cannot fully utilize the essence and qi of heaven and earth, death will ensue.

(Note: "Exceeding by four-fold" means being four times stronger than the normal pulse. Things cannot be excessively strong; extreme excess leads to decay. Whenever the pulse becomes so strong as to reach Guan Ge, it is because Yin and Yang have separated and can no longer nourish each other, leading to weakness and decay. "Ji" means exhaustion. "Jing Qi" refers to innate vitality. It means failing to complete one's natural lifespan and dying prematurely. The Mai Du chapter states: "Pathogens in the Fu organs cause Yang pulse disharmony; Yang pulse disharmony causes Qi stagnation; Qi stagnation leads to excessive Yang. Excessive Yang makes Yin unfavorable; Yin unfavorability causes Blood stagnation; Blood stagnation leads to 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 nourish each other, it is termed 'Guan Ge'. Those with Guan Ge die before their appointed time."

My commentary: The pulse and symptoms of Guan Ge are clearly instructed in the original classics (Nei Jing), yet many people suffer from this disease. However, physicians through the ages have often established their own names for transmission, even losing the fundamental meaning, which is a great error. What is meant by Guan Ge is the blockage and separation of Yin and Yang, inability to mutually nourish and circulate, representing a state of deviation, weakness, and disintegration. Therefore, if only Renying is excessive, the disease is in the Three-Yang Fu organs; if only Cunkou is excessive, the disease is in the Three-Yin Zang organs. Generally, Taiyin distributes Qi to the Three-Yin, and the Qi Kou pulse also belongs to Taiyin; Yangming distributes Qi to the Three-Yang, and the Renying pulse is located beside the larynx. Thus, ancient methods diagnosed the Qi of the Three-Yang at Renying and the Qi of the Three-Yin at Cunkou. As the Si Shi Qi chapter states: "Qi Kou observes Yin, Renying observes Yang." This is precisely what is meant. Regarding Guan Ge syndromes, they arise from extreme excess of Yin or Yang, appearing either at Renying or at Qi Kou. These are all signs of lone Yang rebellion, actually representing the depletion of True Yin. Therefore, depletion of Yin in the Six Fu organs is called Ge Yang; Ge Yang means Yang is rejected by Yin. Depletion of Yin in the Five Zang organs is called Guan Yin; Guan Yin means Yin rejects Yang. Since Yin in both Zang and Fu is depleted, it is called Guan Ge. Although it is called Yin-Yang Guan Ge, implying mutual blockage, why do I refer to them all as Yin depletion? Precisely because extreme pulse excess indicates absence of Yin; without Yin, there is no root, causing lone Yang to float externally. Anyone suffering this will undoubtedly die. I have observed this in individuals like Ku Sima and Tian Zongbo; their pulses were extremely hard and strong, symptoms included increasing wheezing, and even pulses throughout the wrists, neck, and body vibrated incessantly. All these were caused by damage to essence from alcohol and sexual indulgence, ultimately proving incurable. Thus, the Ben Shen chapter states: "The Five Zang store essence; they must not be injured. Injury leads to loss of control and Yin deficiency; Yin deficiency leads to lack of Qi; lack of Qi leads to death." Does this not refer to Guan Yin and Ge Yang?

Furthermore, Guan Ge pulses are discussed repeatedly in chapters such as Liu Jie Zang Xiang, Mai Du, Zhong Shi, Jin Fu, and Jing Mai. This repetition likely stems from concern that the concept is difficult to understand, emphasizing its importance. Yet few later sages grasped its true intent. Was it due to lack of observation? Renying is in the head, belonging to the Yang-Biao (Exterior) pulse of Yangming; thus, Renying twice as large is called Ge Yang. Cunkou is in the hand, belonging to the Yin-Li (Interior) pulse of Taiyin; thus, Cunkou twice as large is called Guan Yin. This is named Guan Ge because Yin and Yang are blocked and separated, and Qi cannot mutually nourish. This definition is immutable.

However, Nan Jing Chapter 3 states: "Pulses have excess, deficiency, Yin-Yang interaction, Fu (overturning), Yi (overflowing), Guan (obstruction), and Ge (rejection). What does this mean?" The answer is: Before the Guan point, Yang moves; the pulse should appear at nine fen and floating. Exceeding this is termed Taiguo (Excess); falling short is termed Bují (Deficiency). If it rises to the Yuji area, it is Yi (Overflow), constituting External Guan and Internal Ge, a pulse of Yin encroaching. After the Guan point, Yin moves; the pulse should appear at one cun and deep. Exceeding this is Taiguo; falling short is Bují. If it sinks into the Chi area, it is Fu (Overturning), constituting Internal Guan and External Ge, a pulse of Yang encroaching. Thus, Zhang Zhongjing followed this saying: "In Chi it is Guan; in Cun it is Ge. Guan results in inability to urinate; Ge results in vomiting and reversal."

Yet, Renying four-fold and Cunkou four-fold do not refer to Cun-Chi positions. Saying "vomiting" refers only to Ge Shi (Food Impediment); saying "inability to urinate" refers only to Long Bi (Dysuria). These conditions do not necessarily lead to death. Why did the original texts emphasize them so heavily? From Wang Shuhe onwards, distinctions were lost, and Guan Ge was explained solely via Cun-Chi positions, claiming Left is Renying and Right is Qi Kou, causing confusion and loss of Yin-Yang and Exterior-Interior principles. Later, Li Dongyuan, following Mai Jing, also claimed Left is Renying and Right is Qi Kou. He stated: If Qi Kou is four times larger than Renying, clear Qi flows in turbid pathways, hence Ge. If Renying is four times larger than Qi Kou, turbid Qi flows in clear pathways, hence Guan. Those following Zhongjing also said Ge causes vomiting and Guan causes difficulty in passing stool. Zhu Danxi even established a specific category for Guan Ge, stating it is mostly fatal, with Cold above and Heat below, and pulses in both Cun positions exceeding four-fold. If both Cun pulses exceed four-fold, how can it be Cold above and Heat below? His theory deviates further, losing meaning, leaving students confused. How can errors be avoided?

Only recently, Ma Xuantai realized the errors of others, stating Guan Ge does not refer to Ge Shi or Long Bi, lamenting: "Alas! Painful! This violates the principles of Xuanti (Yellow Emperor and Qibo)." Qin Yueren, Zhang Zhongjing, Wang Shuhe, Li Dongyuan, and Zhu Danxi are revered by later physicians, yet their interpretations differ so much from Nei Jing. How can lower-level physicians know Guan Ge is a pulse pattern, not a disease name? How can they judge life/death by Guan Ge pulse, treat Guan Ge pulse conditions, or treat Ge and Bi syndromes without error? Mr. Ma's words are correct. However, his annotations fail to detail the classic meaning, erroneously following Wang Shuhe, still using Left as Renying and Right as Qi Kou, ignoring the Yangming Stomach pulse, and losing the fundamental Yin-Yang and Exterior-Interior opposition of the original text. This is another error. In his annotations on Yin Yang Bie Lun regarding "Three-Yang in Head, Three-Yin in Hand," he made erroneous comments. Alas! Mr. Ma mourned predecessors' errors, and I mourn his errors—this is "later generations mourning later generations." If my descendants mourn my errors, I may not realize my faults, and today's words might be better left unsaid.

Qibo said: Those contrary to the Four Seasons, with excess manifest as Jing (Essence/Spirit abundance [of pathogen]), with deficiency manifest as Xiao (Consumption [of healthy Qi]). (Note: Su Wen: Mai Yao Jing Wei Lun. This discusses pulses contrary to the Yin-Yang of the Four Seasons, which also constitute Guan Ge. Jin Fu chapter states: "Spring/Summer Renying slightly large, Autumn/Winter Cunkou slightly large" defines a healthy person. Renying is Yang pulse governing Spring/Summer; Cunkou is Yin pulse governing Autumn/Winter. If contrary: In Spring/Summer, Cunkou should be deficient but is excessive; in Autumn/Winter, Renying should be deficient but is excessive. This is pathogenic excess; excess manifests as Jing (here referring to pathogenic fullness). In Spring/Summer, Renying should be excessive but is deficient; in Autumn/Winter, Cunkou should be excessive but is deficient. This is blood-Qi deficiency; deficiency manifests daily as Xiao (consumption).)

Should be Taiguo (Excess), but is Bují (Deficiency), this is Jing (pathogenic excess); Should be Bují, but is Taiguo, this is Xiao (healthy consumption). Yin and Yang do not correspond; the disease is named Guan Ge.

(Note: For example, in Spring/Summer, Renying should be Taiguo, but Cunkou, which should be Bují, is instead excessive and manifests as Jing (pathogen). In Autumn/Winter, Cunkou should be Taiguo, but Renying, which should be Bují, is instead excessive and manifests as Jing. Here, the deficient side shows excess due to pathogens. In Spring/Summer, Cunkou should be Bují, but Renying, which should be excessive, is deficient and manifests as Xiao. In Autumn/Winter, Renying should be Bují, but Cunkou, which should be excessive, is deficient and manifests as Xiao. Here, the excessive side shows consumption. When deficiency appears as excess, pathogens grow daily; when excess appears as deficiency, healthy Qi declines daily. Such cases represent contrary Yin and Yang, non-interacting Qi, all named Guan Ge. The first two 'Ying' (correspond) are pronounced level tone; the last 'Ying' is pronounced departing tone.)