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Guan (Obstruction) refers to the inability to urinate; Ge (Rebellion) refers to vomiting and regurgitation. This is a condition where both the upper and lower jiao are diseased. "Ge" implies vomiting and regurgitation. The diseases of the nine orifices and five zang organs arise when yin qi reaches its extreme and rises from the earth, which constitutes walking the yang path. This corresponds to the qi of the East, analogous to the transformation of metal and stone, leading to congestion in the upper body. When yin reaches its extreme, the yang path cannot function, and instead closes off at the top, causing vomiting and regurgitation. This occurs because the qi of the earth fails to ascend. If the qi rebels and descends, it instead travels along the yin path, causing qi to fill and block entry into the interior. In this state, the Qi Kou pulse is four times larger than the Ren Ying pulse. This represents clear qi traveling along the turbid path, hence it is called "Ge".

"Guan" refers to difficulty in passing urine. Diseases of the lower orifices and six fu organs arise when yang qi reaches its extreme and descends from heaven, which constitutes walking the yin path. This corresponds to the qi of the West, analogous to the effects of rich and greasy foods, leading to downward leakage. When yang reaches its extreme, the yin path cannot function, and instead closes off at the bottom, causing an inability to urinate. This occurs because the qi of heaven fails to descend and circulate. If the qi rebels and ascends, it instead travels along the yang path, causing blood vessels to become stagnant and blocked. In this state, the Ren Ying pulse is four times larger than the Qi Kou pulse. This represents turbid qi traveling along the clear path, hence it is called "Guan".

One might ask: What is the etiology of Guan-Ge? The answer is: According to the *Nei Jing* (Inner Canon), pathological changes of the zang-fu organs and yin-yang manifest externally through the Ren Ying and Qi Kou pulses. It states that if the Ren Ying pulse is one-fold larger, the disease is in Shaoyang (Lesser Yang); two-fold larger, in Taiyang (Greater Yang); three-fold larger, in Yangming (Bright Yang); and four-fold larger or above, it is called Ge-Yang (Rebellious Yang). If the Cun Kou pulse is one-fold larger, the disease is in Jueyin (Terminal Yin); two-fold larger, in Shaoyin (Lesser Yin); three-fold larger, in Taiyin (Greater Yin); and four-fold larger or above, it is called Guan-Yin (Obstructed Yin). If both the Ren Ying and Cun Kou pulses are盛大 (excessively large), four-fold or more, it is called Guan-Ge. A Guan-Ge pulse that is weak and deficient indicates an inability to align with the essence and qi of heaven and earth, leading to death. The commentary notes that Ge is the extreme excess of yang, causing rejection so that food cannot enter. Guan is the extreme excess of yin, causing closure so that urine cannot pass.

The *Ling Shu* (Spiritual Pivot) also mentions this three times. Two of these instances align with the *Nei Jing*'s discussion on the relative fullness of the Ren Ying and Qi Kou pulses corresponding to specific meridians. However, the *Ling Shu* adds that a full pulse indicates foot meridians, while a full and restless pulse indicates hand meridians. When the Ren Ying pulse is four-fold larger, large and rapid, it is named Yi Yang (Overflowing Yang), which constitutes External Ge. When the Hand Taiyin Cun Kou pulse is four-fold larger, large and rapid, it is named Yi Yin (Overflowing Yin), which constitutes Internal Guan. If Internal Guan does not resolve, the patient will die. If both the Ren Ying and the Taiyin Cun Kou pulses are four-fold or more larger, it is named Guan-Ge, indicating a short life expectancy. If both pulses are three-fold or more larger, it is named Yin-Yang Ju Yi (Simultaneous Overflow of Yin and Yang). If not treated to open the blockage, blood vessels will close, qi will have no pathway, and it will flow freely within, injuring the five zang organs internally.

The principle of acupuncture treatment is as follows: Based on the degree of excess, for Ren Ying pulses one-fold, three-fold, or five-fold larger, one should drain the yang meridian and tonify the paired yin meridian, using a ratio of two drains to one tonification. The same applies to the Cun Kou pulse: drain the yin meridian and tonify the paired yang meridian, using a ratio of two tonifications to one drain. Treatment continues until the upper qi harmonizes. Another theory states that when pathogens are in the fu organs, the yang pulses are discordant. Discordance in yang pulses causes qi stagnation, leading to excessive yang qi. Excessive yang qi hinders yin, causing yin pulse discordance. Discordance in yin pulses causes blood stagnation, leading to excessive yin qi. Excessive yin qi prevents yang qi from nourishing, hence called Guan. Excessive yang qi prevents yin qi from nourishing, hence called Ge. When both yin and yang are excessive and cannot mutually nourish, it is called Guan-Ge. Patients with Guan-Ge will not reach their natural lifespan.

From this perspective, the previous discussions regarding Ren Ying and Cun Kou emphasize that Ren Ying governs the exterior and Qi Kou governs the interior, thus dividing the three yin and three yang meridians based on the magnitude of qi (one-fold, two-fold, three-fold). The discussions that do not mention Ren Ying and Cun Kou likely have deeper implications. Why? Because these were mentioned in the context of discussing pulse dimensions. The twelve meridities of the hands and feet circulate up and down and constitute the major meridional tunnels. However, yin and yang meridities that are exterior-interior pairs of the zang-fu organs have transverse branch pathways connecting the interior and exterior, allowing zang-fu yin-yang qi to mutually nourish each other. Therefore, diagnosis is performed at the six positions (Cun, Guan, Chi) of both wrists. A floating pulse indicates fu disease, and a deep pulse indicates zang disease. Regarding the manifestation of yin-yang excess, does it strictly follow these positions? Thus, the specific mention of Ren Ying and Qi Kou is omitted.

Regarding Zhang Zhongjing's discussion on Guan-Ge, we can observe his views. He stated: If the Cun Kou pulse is floating and large, floating indicates deficiency, and large indicates excess. If located at the Chi position, it is Guan; if at the Cun position, it is Ge. Guan results in urinary retention; Ge results in vomiting and regurgitation. He further stated: If the Heart pulse is洪大 (surging and large) and long, this is the normal pulse of the Heart. If the upper part of the pulse is slightly small, sweating will occur. If the lower part is slightly small but the root is large, it indicates Guan-Ge obstruction with urinary retention. If the head has no sweat, the condition is treatable; if there is sweat, it is fatal. He also said: If the Fu Yang pulse is hidden (Fu) and choppy (Se), a hidden pulse indicates vomiting and regurgitation with undigested food and water; a choppy pulse indicates inability to ingest food, named Guan-Ge.

The Stomach is the sea of water and grain, and the residence of Ying Qi (Nutritive Qi). Ying Qi is the root of Ying and Wei (Defensive) Qi. If the mechanism of Ying Qi does not move, Wei Qi does not distribute. If Wei Qi does not distribute, the pulse becomes hidden (Fu), leading to undigested food, vomiting, and regurgitation. If Ying Qi does not flow, the pulse becomes choppy (Se), leading to inability to ingest food. Such conditions all belong to External Ge, without internal Guan pathology, yet they are collectively referred to as Guan-Ge. Commentators argue that a choppy pulse indicates Spleen disease, and since the Spleen is a yin organ, Spleen disease implies yin excess, which should be Internal Guan, not External Ge preventing food intake. Perhaps the definition of Guan-Ge is clearer: Ge means rejecting and defending against the exterior, preventing entry; Guan means closing the interior, preventing exit. Is this not clear and comprehensive?

Later generations erroneously defined urinary retention as Ge and fecal retention as Guan, referring generally to the yin and yang orifices below, without exploring the fundamental principles of yin-yang. Furthermore, some conflated syndromes of yin-yang separation with Guan-Ge disease, creating confusion and disorder, which is lamentable.

Syndromes of separation recorded in the *Nei Jing* include: "Ge" refers to closure and obstruction, with no communication between upper and lower, caused by sudden severe worry. Commentary states: Worry causes qi to close and fail to move, blood vessels to sever, resulting in inability to pass stool and urine. Another passage states: If a disease persists, transmission and transformation cease, upper and lower do not connect, and even skilled physicians may find it difficult to treat. Another states: "San Yang Jie" (Binding of Three Yang) is called Ge. Commentary explains: Heat binding in the Small Intestine and Bladder. Heat binding in the Small Intestine dries the blood vessels; heat binding in the Bladder depletes body fluids, causing obstruction and difficulty in elimination. Another states: Accumulation in San Yang leads to blockage of all nine orifices. Another states: Death due to yang accumulation occurs when yang qi is obstructed; obstruction requires purgation. Failure to treat correctly and urgently allows incompetent physicians to worsen the condition.

Investigating these passages, what is their relation to Guan-Ge? Danxi's writings state: One must use emesis to lift the horizontally obstructed qi; it is not necessary to actually expel phlegm. He also stated: For phlegm syndromes, use Er Chen Tang to induce vomiting; vomiting inherently contains the action of descending qi. For those with impaired middle qi transport, add ascending and descending herbs to tonifying formulas. This seems to have borrowed methods for treating urinary issues and applied them indiscriminately, perpetuating secular errors without realization, which is tragic.

Furthermore, consulting Wang Shuhe's *Mai Jing* (Pulse Classic), citing the 81st Difficulty of the *Nan Jing*: There are excesses, deficiencies, mutual multiplication of yin and yang, Fu (overturning), Yi (overflowing), Guan, and Ge. Before the Guan position is the movement of yang; the pulse should appear at nine fen and float. Exceeding this is termed "Excess"; falling short is termed "Deficiency". Extending up to the fish border is Yi (Overflow), constituting External Guan and Internal Ge, which is a pulse of yin multiplying. After the Guan position is the movement of yin; the pulse should appear at one cun and sink. Exceeding this is "Excess"; falling short is "Deficiency". Extending into the Chi position is Fu (Overturning), constituting Internal Guan and External Ge, which is a pulse of yang multiplying. Therefore, Fu and Yi represent the True Zang pulses; even without apparent illness, death will occur naturally. Generally, these are also mutual manifestations of Ren Ying and Qi Kou pulses.

Yun Qizi stated: When yin and yang change positions, the disease is named Guan-Ge. If yang qi constantly resides in the chest and diaphragm, heat is the primary pathology. If yin qi constantly resides below the waist, cold is the primary pathology. If cold is in the chest, with a white coating on the tongue and inability to swallow liquids, it is called Ge, characterized by vomiting and regurgitation. If heat is in the Dantian, with urinary retention, it is called Guan, characterized by inability to urinate. Chest cold is treated with hot medicines; Dantian heat is treated with cold medicines. If both chest cold and heat coexist, treat according to the master-guest method: treating the master condition should be slow, treating the guest condition should be urgent. Formulas include Baizi Ren Tang, Renshen San, Ji Ji Wan, Binglang Yiqi Tang, Mutong Erchen Tang, Daoqi Qingli Tang, Jiawei Maren Wan, and Zaogao San.

Sun Shangyao treated the daughter of Zhao Lingyi, a Fengzhi official, who suddenly presented with vomiting and regurgitation, inability to pass stool and urine, restlessness, gradual coldness of the four limbs, and absence of pulse. After one and a half days, a dose of Dachengqi Tang was administered. By midnight, bowel movements gradually resumed, the pulse became harmonious, and she stabilized the next day.