凡阴气太盛。阳气不得相营曰关。阳气太盛。阴气不得相营曰格。阳气不能营于阴。阴脉上出而溢于鱼际。为外关
内格。外关内格者。乃阴脉乘阳。阳外闭而不下。阴内出以格拒之也。其为病。外热液汗不通。内寒胸满吐食。阴气不
能营于阳。阳脉下陷而覆于尺部。为内关外格。内关外格者。乃阳脉乘阴。阴内闭而不上。阳从外入以格拒之也。其为
病。内热大小便闭。外寒手足厥冷。其脉有阴阳相乘。有复有溢。皆于此会。
脉语曰。表症。汗之常也。病发热头痛脉反沉。仲景急救其里。用四逆汤。此从脉之沉也。里症。下之常也。日晡
发
热属阳明。脉浮虚宜发汗。此从脉之浮也。结胸证具。常以大小陷胸汤下之矣。脉若浮大不可下。下之即死。是宜从脉。
而治其表也。身疼痛。常以桂枝麻黄汗之矣。尺中迟不可汗。以荣气不足。血少故也。是宜从脉。而调其荣矣。此皆从
脉不从症也。世有问症而忽脉者。得非仲景之罪人乎。
脉语曰。脉浮为表。汗之常也。亦有宜下者。脉浮大。心下硬也。脉沉为里。下之常也。亦有宜汗者。少阴病。始
得之反发热。麻黄附子细辛汤微汗之是也。脉促阳盛。常用葛根芩连清之矣。若脉促厥冷。为虚脱。非灸非温不可。
此又非促为阳盛之脉也。脉迟阴寒。常用干姜附子温之矣。若阳明脉迟。不恶寒。身体 汗出。则用大承气。此又非
诸迟为寒之脉矣。是皆从症不从脉也。世有切脉而不问症者。其失可胜言哉。
When Yin Qi (Yin Energy) is excessively abundant and Yang Qi (Yang Energy) cannot interact harmoniously with it, this is termed "Guan" (Obstruction). When Yang Qi is excessively abundant and Yin Qi cannot interact harmoniously with it, this is termed "Ge" (Rejection). When Yang Qi fails to nourish the Yin aspect, causing the Yin pulse to rise and overflow to the Yuji area (the fleshy part at the base of the thumb), this is called "External Guan and Internal Ge". In the case of External Guan and Internal Ge, the Yin pulse invades the Yang position; Yang Qi is externally blocked and cannot descend, while Yin Qi emerges from within to reject Yang Qi. The resulting pathology manifests as external heat with an inability to sweat or circulate fluids, and internal cold with chest fullness and vomiting of food. When Yin Qi fails to nourish the Yang aspect, causing the Yang pulse to sink and subside into the Chi position (wrist pulse position closest to the elbow), this is called "Internal Guan and External Ge". In the case of Internal Guan and External Ge, the Yang pulse invades the Yin position; Yin Qi is internally blocked and cannot ascend, while Yang Qi enters from the exterior to reject Yin Qi. The resulting pathology manifests as internal heat with constipation and urinary retention, and external cold with cold limbs. The pulse patterns involve mutual invasion of Yin and Yang, recurrence, and overflow, all converging in these conditions.
The *Mai Yu* (Discourse on Pulses) states: For Exterior Syndromes (Biao Zheng), sweating is the standard treatment. However, if a patient presents with fever and headache but the pulse is unexpectedly deep (Chen), Zhang Zhongjing advocates urgently tonifying the Interior (Li), using Sini Tang (Four Reversal Decoction). This follows the pulse (deepness) rather than the symptoms. For Interior Syndromes, purgation is the standard treatment. If afternoon tidal fever indicates a Yangming Syndrome (Yang Ming Bing), but the pulse is floating and deficient, sweating is appropriate. This follows the pulse (floatingness) rather than the symptoms. In cases of Jie Xiong (Chest Binding) syndrome where indications are complete, Da Xian Xiong Tang (Major Chest-Binding Decoction) or Xiao Xian Xiong Tang (Minor Chest-Binding Decoction) are typically used for purgation. However, if the pulse is floating and large, purgation is contraindicated; purging will lead to death. In such cases, one should follow the pulse and treat the Exterior. For body pain, Guizhi Tang (Cinnamon Twig Decoction) or Mahuang Tang (Ephedra Decoction) are typically used for sweating. However, if the Chi position pulse is slow (Chi), sweating is contraindicated because Ying Qi (Nutritive Energy) is insufficient and blood is scant. In such cases, one should follow the pulse and regulate the Ying Qi. These are all instances of "following the pulse over the symptoms." Those in the world who inquire about symptoms but neglect the pulse—would they not be sinners against Zhang Zhongjing?
The *Mai Yu* states: A floating pulse indicates an Exterior condition, and sweating is the standard treatment. Yet, there are cases suitable for purgation, such as when the pulse is floating and large accompanied by hardness below the heart. A deep pulse indicates an Interior condition, and purgation is the standard treatment. Yet, there are cases suitable for sweating, such as Shaoyin Disease (Shao Yin Bing) presenting with fever upon initial onset; here, Mahuang Fuzi Xixin Tang (Ephedra, Aconite, and Asarum Decoction) is used to induce mild sweating. A rapid/intermittent pulse (Cu Mai) usually indicates excessive Yang heat, treated with Gegen Qinlian Tang (Kudzu and Scutellaria-Coptis Decoction) for clearing. However, if the pulse is Cu accompanied by cold limbs, it indicates collapse due to deficiency, requiring moxibustion and warming; this is no longer treating Cu as a pulse of Yang excess. A slow pulse (Chi Mai) usually indicates Yin cold, treated with Ganjiang Fuzi (Dried Ginger and Aconite) for warming. However, in Yangming disease, if the pulse is slow but there is no aversion to cold and the body sweats, Dachengqi Tang (Major Order the Qi Decoction) is used. This is no longer treating all slow pulses as signs of cold. These are all instances of "following the symptoms over the pulse." Those in the world who palpate the pulse without asking about symptoms—how can their errors be fully described?