经义
人迎一盛，病在少阳，二盛病在太阳，三盛病在阳明，四盛以上为格阳。寸口一盛，病在厥阴，二盛病在
少阴，三盛病在太阴，四盛以上为关阴。人迎与寸口俱盛，四倍以上，为关格。关格之脉羸不能极于天地之精
气则死矣。（《素问》）
五脏不和，则九窍不通；六腑不和，则留结为痈。邪在六腑，则阳脉不和；阳脉不和，则气留之；气留之，
则阳脉盛矣。邪在五脏，则阴脉不和；阴脉不和，则血留之；血留之，则阴脉盛矣。阴气太盛，则阳气不得相
荣也，故曰格。阳气太盛，则阴气不得相荣也，故曰关。阴阳俱盛，不得相荣也，故曰关格。关格者，不得尽
其命而死矣。○上鱼为溢，为外关内格。入尺为覆，为内关外格。（《难经》）
哲言
寸口脉浮而大，浮为虚，大为实；在尺为关，在寸为格；关则不得小便，格则吐逆。○心脉洪大而长，上
微头小者，则汗出；下微本大者，则关格不通，不得尿。头无汗者可治，有汗者死。○趺阳脉伏而涩，伏则吐逆，
水谷不化，涩则食不得入，名曰关格。（张仲景）
关则不得小便，格则吐逆。关者甚热之气，格者甚寒之气。是关者无出之由，格者无入之理。寒在胸中，
遏绝不入；热在下焦，填塞不出。（张洁古）
关格者，谓膈中觉有所碍，欲升不升，欲降不降，欲食不食，此为气之横格。（戴复庵）
走哺，由下不通，浊气上冲，而饮食不得入。关格，由上下阴阳之气倒置，上不得入，下不得出。（《医阶辨证》）
关格一证，在《内经》本言脉体，以明阴阳离绝之故。自秦越人以尺寸言关格，已失本经之意矣。又仲景
曰∶在尺为关，在寸为格；关则不得小便，格则吐逆。故后世自叔和、东垣以来，无不以此相传，而竞置关格
一证于乌有矣。再至丹溪，则曰此证多死。寒在上，热在下，脉两寸俱盛四倍以上，法当吐以提其气之横格。
愚谓两寸俱盛四倍，又安得为寒在上耶？且脉大如此，则浮豁无根，其虚可知，又堪吐乎？谬而谬又，莫此为
甚！夫《内经》云人迎寸口，既非尺寸之谓，而曰吐逆者，特隔食一证耳；
曰不得小便者，特癃闭一证耳。二证自有本条，其与关格何涉？数子且然，况其他乎？○《经》曰∶人迎四盛
以上为格阳；寸口四盛以上为关阴；人迎与寸口俱盛，四倍以上，为关格。此关格之证，以脉言，不以病言也。
今人患此颇多，而人多不知，但其两手之脉，浮弦数极，大至四倍以上者，便是此证。其病必虚里跳动，而气
喘不已；此之喘状，多无咳嗽，但觉胸膈舂舂，似胀非胀，似短非短，微劳则喘甚，多言亦喘甚，甚至遍身振
振，慌张不定。此必情欲之伤，以致元气无根，孤阳离剧之候也，多不可治。（张景岳）
按∶《内经》所言，人迎与寸口俱盛，四倍以上为关格。是以阳经取决于人迎，阴经取决于寸口也。越人
云∶上鱼为溢，为外关内格；入尺为覆，为内关外格。仲景亦谓在尺为关，在寸为格；关则不得小便，格则
吐逆。皆以阳分取决于寸口，阴分取决于尺内也。《难经》又言∶上部有脉，下部无脉，其人当吐不吐者死；
仲景又有趺阳脉伏而涩，伏则吐逆，水谷不化，涩则食不得入，名曰关格。则知关格之脉证不一也。而马仲化
释《内经》，谓关格之义，非隔食、癃闭之证。张介宾直将越人、仲景之言，一概非之，独执人迎在颈，为阳
明之表脉，遂诋东垣、丹溪皆仍叔和《脉经》左为人迎、右为气口之谬。呜呼！《内经》固为圣经，确宜遵从，
而越人、仲景之书，未尝不为圣经也。盖人迎气口，所以分表里之阴阳；寸口尺内，所以分上下之阴阳也。人
一身表里上下之气化，皆肺所司，血脉皆心所主，故凡气血之盛衰，靡不变见于气口，气口实为肺经之一脉，
不过分其部位，以候他脏之气耳。即如仲景所指趺阳少阴，虽主于足，然未尝不于关尺推之；则《内经》所言
人迎气口，候之左右亦无不可也。故释《内经》之关格，但当言是表里阴阳痞绝之候，不当与上吐下闭之关格
混同立论则可；若言上吐下闭，当称隔食癃闭，不得名为关格则不可。或言关格之证，其脉未必皆然则可；若
言关格之脉，必无在
尺在寸之分则不可。（《张氏医通》）
关格之为病，世多不得其解，不知《内经》分人迎、寸口，其言早已明析。人迎统三阳，寸口统三阴；统
三阳者胃也，统三阴者肺也。阳曰格，言其阻；阴曰关，言其闭。经未明言，所患何证，犹为难测。仲景为解
曰∶关则不得小便，格则吐逆，则明显易解矣。阳明主纳水谷，三阳同阻于阳明，水谷何由入？太阴主调水道，
三阴同闭于太阴，水道何由调？治者不从肺胃求责，或以为阳反在下，阴反在上；或以为阳格乎阴，阴拒乎阳；
或谓阴阳不交，各造其偏，均未得谛当也。○关格一证，前本仲景之说为解，其实仲景所言，但关格中之一病
耳。谓吐逆不得小便，为非关格，不可也。以为遂足以尽关格之病，亦不可也。阴阳本自贯通，关格则阴阳各
聚于一区。《内经》言脉不言证，其所包者广可知。故凡阴阳两不相顾，而病多分见者，皆关格之类也。○阴
病救阴，阳病救阳，阴阳同病，则阴阳同救。阴阳皆病，而分见者，其将何以措手乎？由是言之，吐逆不得小
便，但为关格之先兆。他如干霍乱之欲吐不得吐，欲泻不得泻，或一身而寒热各半，或一病而阴阳混淆者，皆
关格之类，而不得为真关格。真关格者，无药可医，不得尽期而死。（《医参》）
补编
关格虽有数种，然总由肝郁为病，以肝主疏泄故也。治用逍遥散，加山栀、车前以降逆，柴胡以升木郁，
乃和解之意。（陈士铎）
关格者，暴病也。大小便秘，渴饮呕吐，唇燥面赤，脉息沉伏，此寒从少阴而入，阴盛于下，逼阳于上。
须以白通汤，寒因热用，和人尿、猪胆咸苦之物于温热药中，其气相从，可去拒格之寒也。服药脉渐出者生，
乍出者死。（《赵氏医贯》）
《内经》曰∶病久则传化，上下不并，良医弗为。此正指关格而言也。不并犹言不交也，阳在上者不能下，
阴在下者不能上，则天地不交，而运化之机缄穷矣。欲降其阳则阴伤，欲升其阴则阳
败，故古人立方，不治其寒热，而以通达窍者宜之。（《见闻录》）
关格所伤，根本已甚，药饵固不可废。如精虚者，当补其精；气虚者，当益其气。然必须远居别室，静养
澄心，假以岁月，斯可保全。若不绝谢人事，但靠药饵，终无济也。（张景岳）
关格之证，自《灵》、《素》以及《难经》、仲景脉法，皆深言之，然无其方也。后世以无成方根据傍，其
中元言奥义，总不参研，空存其名久矣。惟云岐子述其阴阳反背之状，传其所试九方。其谓阴阳易位，病名关
格。胸膈以上，阳气常在，则热为主病；身半以下，阴气常在，则寒为主病。胸中有寒，以热药治之；丹田有
热，以寒药治之。若胸中寒热兼有，以主客之法治之。治主当缓，治客当急。此从《伤寒论》胸中有寒，丹田
有热立说，实非关格本证。所引《内经》运气治主客之法，亦属无据。至于《灵》、《素》、《难经》、《金
匮》之文，绝不体会，所定诸方，浑入后人恶劣窠臼。方中小疵，杂用二陈、五苓、枳壳、浓朴、槟榔、木香
是也。方中大疵，杂用片脑、麝香、附子、皂角、牵牛、大黄、朴硝是也。夫阴阳不交，各造其偏，而谓阴反
在上阳反在下，可乎？九死一生之证，而以霸术劫夺其阴阳，可乎？仲景之以趺阳为诊者，正欲人调其营卫，
不偏阴偏阳，一味冲和无忤，听胃气之自为敷布，得协于平也。岂一蹴所能几耶？故不问其关于何而开，格于
何而通，一惟求之于中，握枢而运。治吐逆之格，由中而渐透于上；治不溲之关，由中而渐透于下；治格而且
关，由中而渐透于上下。姑立进退黄连汤一方，要未可为中人道也。○黄连汤者，仲景治伤寒之方也；以其胃
中有邪气，阻遏阴阳升降之机，而不交于中土，于是阴不得升，而独治于下，为下寒，腹中痛；阳不得降，而
独治于上，为胸中热，欲呕吐，与此汤以升降阴阳固然矣。而湿家下之，舌上如苔者，丹田有热，胸中有寒，
亦用此汤何耶？盖伤寒分表、里、中三治，表里之邪俱盛，则从中而和之，故有小柴胡之和法。饮入胃中，听
胃气之升者，
带柴胡出表；胃气之降者，带黄芩入里，一和而表里之邪尽服，不相扦格矣。至于丹田胸中之邪，则在于上下，
而不为表里，即变柴胡汤为黄连汤，和其上下。饮入胃中，亦听胃气之上下敷布，故不问其上热下寒，上寒下
热，皆可治之也。夫表里之邪，则用柴胡、黄芩；上下之邪，则用桂枝、黄连。表里之邪，则用生姜以散之；
上下之邪，则用干姜以开之。仲景圣法昭然矣。昌欲进退其上下之法，求之于中，握枢而运，以渐透于上下。
格则吐逆，进而用此方为宜。盖太阳主开，太阳不开，则胸间窒塞，食不得入，入亦复出，以桂枝为太阳经药，
和营卫而行阳道，故能开之也。至于五志厥阳之火上入，桂枝又不可用矣，用之则以火济火，头有汗而阳脱矣。
其关则不得小便，退之之法，从胃气以透入阴分，桂枝亦在所不取。但胃之关门已闭，少阴主阖，少阴之气不
上，胃之关门必不开。《经》曰∶肾气独沉。又曰∶肾气不衡。夫真气之在肾中，犹权衡也，有权有衡，则关
门时开时阖。有权无衡，则关门有阖无开矣，小溲亦何从而出耶？是则肾气丸，要亦退之之中所有事矣。肾气
交于胃，则关门开，交于心，则厥阳之火随之下伏，有不得不用之时矣。○凡治关格病，不知批 导 ，但冀
止呕利溲，亟治其标，技穷力竭，无益反损，医之罪也。○凡治关格病，不参人迎、趺阳、太冲，独持寸口，
已属疏略。若并寸口阴阳之辨懵然，医之罪也。○凡治关格病，不辨脉之阳虚阳实，阴虚阴实，而进退其治，
肓人适路，不辨东西，医之罪也。○凡治关格病，不从王道，辄投霸术，逞己之能，促人之死，医之罪也。（《医门法律》）
附方
进退黄连汤 黄连姜汁炒一钱五分、干姜炮一钱五分、人参人乳拌蒸一钱五分、桂枝一钱、半夏姜制一钱
五分、大枣二枚。进法∶用本方六味俱不制，水三茶盏，煎一盏半，温服。退法∶不用桂枝，黄连减半，或
加肉桂五分，如上逐味制熟，煎服法同。
朝服八味丸三钱，半饥服煎剂。
资液救焚汤 治五志厥阳之火。生地黄取汁二钱、麦门冬取汁二钱、人参人乳拌蒸一钱五分、胡麻仁炒研一
钱、柏子仁炒七分、甘草炙一钱、五味子四分、紫石英敲碎一钱、阿胶一钱、寒水石敲碎一钱、滑石敲碎一钱、
犀角磨汁三分、生姜汁三匙。上除四汁、阿胶，其八味用水四茶杯，缓火煎至一杯半；去渣、入四汁、阿胶，
再煎至胶烊化；斟出，调牛黄五厘。日中分二、三次热服。空朝先服八味丸三钱。
【经典论述】
人迎脉比寸口脉大一倍，病在少阳；大两倍，病在太阳；大三倍，病在阳明；大四倍以上，称为格阳。寸口脉比人迎脉大一倍，病在厥阴；大两倍，病在少阴；大三倍，病在太阴；大四倍以上，称为关阴。如果人迎脉和寸口脉都盛大，且大四倍以上，称为关格。关格的脉象羸弱，不能承受天地之精气，则会导致死亡。（出自《素问》）
五脏功能不和，则九窍不通畅；六腑功能不和，则气机留滞结聚而成痈肿。邪气侵犯六腑，则阳脉不和；阳脉不和，则气机留滞；气机留滞，则阳脉盛大。邪气侵犯五脏，则阴脉不和；阴脉不和，则血行留滞；血行留滞，则阴脉盛大。阴气过于盛大，阳气就不能与之相互营卫调和，所以称为“格”。阳气过于盛大，阴气就不能与之相互营卫调和，所以称为“关”。阴阳二气都盛大，彼此不能相互营卫调和，所以称为“关格”。患关格病的人，寿命将尽而死。○脉搏上鱼际为溢脉，属于外关内格。脉搏下入尺部为覆脉，属于内关外格。（出自《难经》）
【哲人言论】
寸口脉浮而大，浮表示虚证，大表示实证；脉见于尺部为关，脉见于寸部为格；关证则小便不通，格证则呕吐逆反。○心脉洪大而长，若脉头小根部大，则汗出；若脉头小根部大（注：此处原文逻辑可能有误或指代特定形态，依文意译为：下部微大），则关格不通，小便不得排出。头部无汗者可治，有汗者死。○趺阳脉伏而涩，伏脉主呕吐逆反，水谷不化；涩脉主饮食难以下咽，这种病症称为关格。（张仲景）
关证是小便不通，格证是呕吐逆反。关证是由于极热之气阻滞，格证是由于极寒之气阻隔。因此，关证没有排出的途径，格证没有进入的道理。寒气停留在胸中，阻碍食物进入；热气积聚在下焦，堵塞排泄物无法排出。（张洁古）
关格病，是指膈中感觉有阻碍，想升不能升，想降不能降，想吃吃不下，这是气机横逆阻隔所致。（戴复庵）
走哺症，是由下部不通，浊气上冲，导致饮食无法进入。关格病，是由上下阴阳之气倒置，上部食物不能进入，下部排泄物不能排出。（《医阶辨证》）
关格这一病症，在《内经》中原本是指脉象，用以说明阴阳离绝的原因。自从秦越人（扁鹊）用尺寸脉来解释关格，就已经失去了《内经》的本意了。另外张仲景说：脉见于尺部为关，脉见于寸部为格；关证则小便不通，格证则呕吐逆反。因此后世从王叔和、李东垣以来，无不以此相传，从而完全忽略了关格这一病症的真实含义。到了朱丹溪，他说此证大多致死。认为寒在上，热在下，两手寸脉都盛大四倍以上，应当用吐法以提举横格之气。我认为两手寸脉都盛大四倍，又怎么能说是寒在上呢？而且脉象如此盛大，则是浮豁无根，其虚损可知，又怎么可以用吐法呢？错误叠加错误，没有比这更严重的了！《内经》所说的人迎、寸口，并不是指尺寸的脉位；所说的吐逆，特指噎食一证；所说的小便不通，特指癃闭一证。这两个证候自有专门的条文论述，与关格有什么关系？这几位医家尚且如此，何况其他人呢？○《内经》说：人迎脉大四倍以上为格阳；寸口脉大四倍以上为关阴；人迎与寸口脉都盛大，大四倍以上，为关格。这个关格的定义，是从脉象而言，不是从病症而言。现在人患此病很多，但人们多不知道，只要两手脉象浮弦数极，大至四倍以上，就是此证。其病症必定出现虚里跳动，并且气喘不止；这种喘状，多没有咳嗽，只感觉胸膈悸动不安，似胀非胀，似短气非短气，稍微劳累则气喘加重，多说几句话也气喘加重，甚至全身震颤，慌张不定。这必定是情欲损伤，导致元气无根，孤阳离决的征候，大多不可治愈。（张景岳）
按语：《内经》所言，人迎与寸口脉都盛大，大四倍以上为关格。这是以阳经取决于人迎脉，阴经取决于寸口脉。秦越人说：上鱼际为溢脉，为外关内格；下入尺部为覆脉，为内关外格。张仲景也说：脉见于尺部为关，脉见于寸部为格；关证则小便不通，格证则呕吐逆反。这些都是以阳分取决于寸口，阴分取决于尺部。《难经》又说：上部有脉，下部无脉，其人应当呕吐却不呕吐的会死；张仲景又有趺阳脉伏而涩，伏脉主呕吐逆反，水谷不化，涩脉主饮食难以下咽，称为关格。由此可知关格的脉证并不单一。而马仲化解释《内经》，认为关格的意义，并非隔食、癃闭之证。张介宾直接将秦越人、张仲景的话一概否定，独自坚持人迎脉在颈部，是阳明经的表脉，于是诋毁李东垣、朱丹溪仍然沿袭王叔和《脉经》中左为人迎、右为气口的谬误。唉！《内经》固然是圣经，确实应该遵从，但秦越人、张仲景的书籍，也未尝不是圣经啊。大概人迎、气口，是用来分辨表里的阴阳；寸口、尺部，是用来分辨上下的阴阳。人身上一身表里上下之气化，都由肺所主管，血脉都由心所主宰，所以凡是气血的盛衰，无不显现于气口，气口实际上是肺经的一条脉，不过是区分部位，以诊察他脏之气罢了。就像张仲景所指出的趺阳脉、少阴脉，虽然主于足部，但也未尝不在关尺部推求；那么《内经》所说的人迎、气口，诊察左右也没有不可以的。所以解释《内经》的关格，只应当说是表里阴阳痞塞隔绝的征候，不应当与上吐下闭的关格混同立论就可以了；如果说上吐下闭，应当称为噎食、癃闭，不能命名为关格，那就不对了。或者说关格病的脉象未必都是这样是可以的；如果说关格的脉象，必然没有在尺部、在寸部的区分，那就不对了。（《张氏医通》）
关格这种病，世人大多不能理解，不知道《内经》区分人迎、寸口，其说法早已明确。人迎统管三阳经，寸口统管三阴经；统管三阳的是胃，统管三阴的是肺。阳称为格，是说其阻遏；阴称为关，是说其闭塞。经文没有明确说明患的是什么证，所以还难以推测。张仲景加以解释：关证则小便不通，格证则呕吐逆反，这样就明显容易理解了。阳明胃主受纳水谷，三阳经同受阻于阳明，水谷从哪里进入？太阴脾主调节水道，三阴经同闭塞于太阴，水道从哪里调节？治疗者不从肺胃寻找病因，有的认为是阳反而在下，阴反而在上；有的认为是阳格拒阴，阴抗拒阳；有的说是阴阳不交，各自造成偏颇，都没有得到确切的道理。○关格这一证，之前本依据张仲景的说法来解释，其实张仲景所说的，只是关格中的一种病罢了。说呕吐逆反和小便不通不是关格，是不对的；认为这就足以穷尽关格的所有病症，也是不对的。阴阳本是贯通的，关格则阴阳各自聚集在一区。《内经》讲脉不讲证，其所包含的范围广泛可知。所以凡是阴阳两不相顾，而病症多分别出现的，都属于关格之类。○阴病救阴，阳病救阳，阴阳同病，则阴阳同救。阴阳都病了，而且分别出现症状，该怎么办呢？由此说来，呕吐逆反和小便不通，只是关格的前兆。其他如干霍乱想吐吐不出，想拉拉不出，或者一身寒热各半，或者一个病中阴阳混淆的，都属于关格之类，但不是真正的关格。真正的关格，无药可医，活不到预定期限就会死。（《医参》）
【补编】
关格虽然有数种，但总归是由肝郁致病，因为肝主疏泄的缘故。治疗用逍遥散，加山栀、车前子以降逆，柴胡以升发木郁，这是和解的意思。（陈士铎）
关格病，是暴病。大小便秘结，口渴饮水，呕吐，嘴唇干燥面色红赤，脉象沉伏，这是寒邪从少阴经而入，阴盛于下，逼迫阳气于上。必须用白通汤，采用寒因热用的方法，在人尿、猪胆汁等咸苦之物中加入温热药中，使药气相从，可以去除拒格之寒。服药后脉象逐渐出现的能生，突然出现的会死。（《赵氏医贯》）
《内经》说：病久则传变，上下不并，良医也无能为力。这正是指关格而言。不并犹言不交，阳在上者不能下行，阴在下者不能上行，则天地不交，而运化的机制就穷尽了。想要降其阳则伤阴，想要升其阴则败阳，所以古人立方，不治其寒热，而以通达窍道为宜。（《见闻录》）
关格所伤的，根本已经非常严重，药物固然不可废弃。如精虚者，应当补其精；气虚者，应当益其气。然而必须远离尘世居所，静养澄心，假以时日，才可以保全。如果不谢绝人事往来，只依靠药物，最终是没有帮助的。（张景岳）
关格之证，自《灵枢》、《素问》以及《难经》、张仲景脉法，都深入论述过，然而没有现成的方剂。后世因为没有成方作为根据傍依，其中元妙的奥义，总不参研，空存其名很久了。只有云岐子叙述其阴阳反背的状态，传授他所试用的九方。他说阴阳易位，病名关格。胸膈以上，阳气常在，则以热为主病；身半以下，阴气常在，则以寒为主病。胸中有寒，用热药治疗；丹田有热，用寒药治疗。如果胸中寒热兼有，用主客法治之。治主当缓，治客当急。这是从《伤寒论》胸中有寒，丹田有热立论，实际上并非关格的本证。所引用的《内经》运气治主客之法，也属无据。至于《灵枢》、《素问》、《难经》、《金匮要略》的原文，绝不体会，所定的诸方，混杂后人恶劣的窠臼。方中的小毛病，杂用二陈汤、五苓散、枳壳、厚朴、槟榔、木香等。方中的大毛病，杂用冰片、麝香、附子、皂角、牵牛子、大黄、芒硝等。阴阳不交，各自造成偏颇，却说阴反而在上阳反而在下，可以吗？九死一生的证候，却用霸道的手段劫夺其阴阳，可以吗？张仲景以趺阳脉为诊察对象，正是希望人调理营卫，不偏阴偏阳，一味冲和无忤，听任胃气自行敷布，达到协调平衡。难道是一蹴而就就能做到的吗？所以不问其关于何而开，格于何而通，一律从中求取，掌握枢纽而运转。治疗呕吐逆反的格证，由中而渐透于上；治疗小便不通的关证，由中而渐透于下；治疗既格且关的，由中而渐透于上下。暂立进退黄连汤一方，大概不足以对中道之人谈论。○黄连汤，是张仲景治疗伤寒的方子；因为其胃中有邪气，阻遏阴阳升降之机，而不交于中土，于是阴不得升，而独治于下，成为下寒，腹中痛；阳不得降，而独治于上，成为胸中热，想呕吐，给予此汤以升降阴阳固然可以。但是湿家误下，舌上如苔者，丹田有热，胸中有寒，也用此汤为什么呢？大概伤寒分表、里、中三治，表里之邪俱盛，则从中而和之，所以有小柴胡汤的和法。药饮入胃中，听任胃气上升者，带柴胡出表；胃气下降者，带黄芩入里，一和而表里之邪尽除，不相扦格了。至于丹田胸中之邪，则在于上下，而不为表里，即变柴胡汤为黄连汤，和其上下。药饮入胃中，也听任胃气上下敷布，所以不论其上热下寒，上寒下热，都可以治疗。表里之邪，则用柴胡、黄芩；上下之邪，则用桂枝、黄连。表里之邪，则用生姜以散之；上下之邪，则用干姜以开之。张仲景的圣法昭然可见。我想进退其上下之法，求之于中，掌握枢纽而运转，以渐透于上下。格证则呕吐逆反，进法用此方为宜。盖太阳主开，太阳不开，则胸间窒塞，食物不得进入，进入也复出，以桂枝为太阳经药，和营卫而行阳道，故能开之。至于五志厥阳之火上入，桂枝又不可用了，用了就是以火济火，头有汗而阳脱了。其关证则小便不通，退法，从胃气以透入阴分，桂枝也在所不取。但胃之关门已闭，少阴主阖，少阴之气不上，胃之关门必不开。《内经》说：肾气独沉。又说：肾气不衡。真气在肾中，犹如权衡，有权有衡，则关门时开时阖。有权无衡，则关门有阖无开，小便又从哪里出来呢？那么肾气丸，也是退法中所必要的事。肾气交于胃，则关门开，交于心，则厥阳之火随之而下伏，有不得不用之时了。○凡治疗关格病，不知批导，只希望止呕利溲，急切治疗其标，技穷力竭，无益反损，是医生的罪过。○凡治疗关格病，不参看人迎、趺阳、太冲脉，只持寸口脉，已经属疏忽遗漏。如果连寸口阴阳的辨别都懵懂无知，是医生的罪过。○凡治疗关格病，不辨脉之阳虚阳实，阴虚阴实，而进退其治，如同盲人走路，不辨东西，是医生的罪过。○凡治疗关格病，不从王道，辄投霸术，逞己之能，促人之死，是医生的罪过。（《医门法律》）
【附方】
进退黄连汤 黄连用姜汁炒一钱五分、干姜炮制一钱五分、人参用人乳拌蒸一钱五分、桂枝一钱、半夏姜制一钱五分、大枣二枚。进法：用本方六味均不特殊炮制，水三茶盏，煎至一盏半，温服。退法：不用桂枝，黄连减半，或加肉桂五分，如上逐味制熟，煎服法相同。
早晨服用八味丸三钱，半饥时服用煎剂。
资液救焚汤 治疗五志厥阳之火。生地黄取汁二钱、麦门冬取汁二钱、人参用人乳拌蒸一钱五分、胡麻仁炒研一钱、柏子仁炒七分、甘草炙一钱、五味子四分、紫石英敲碎一钱、阿胶一钱、寒水石敲碎一钱、滑石敲碎一钱、犀角磨汁三分、生姜汁三匙。以上除了四种汁液和阿胶，其余八味用水四茶杯，慢火煎至一杯半；去渣，加入四种汁液、阿胶，再煎至胶融化；斟出，调牛黄五厘。日中分二、三次热服。空腹早晨先服用八味丸三钱。
[Classic Discourse]
When the Renying pulse is one times larger than the Cunkou pulse, the disease is in Shaoyang (Lesser Yang); two times larger, the disease is in Taiyang (Greater Yang); three times larger, the disease is in Yangming (Yang Brightness); four times larger or more, it is called Ge Yang (Rebellious Yang). When the Cunkou pulse is one time larger than the Renying pulse, the disease is in Jueyin (Terminal Yin); two times larger, the disease is in Shaoyin (Lesser Yin); three times larger, the disease is in Taiyin (Greater Yin); four times larger or more, it is called Guan Yin (Closed Yin). If both the Renying and Cunkou pulses are vigorous and four times larger or more, it is called Guan Ge (Guan-Ge syndrome). The Guan Ge pulse is emaciated and cannot sustain the essence and Qi of Heaven and Earth, leading to death. (From *Su Wen*)
When the Five Zang organs are not in harmony, the Nine Orifices will be obstructed; when the Six Fu organs are not in harmony, Qi stagnation leads to accumulation and formation of carbuncles. Evil invading the Six Fu organs causes disharmony of the Yang pulses; disharmony of the Yang pulses causes Qi stagnation; Qi stagnation leads to an excess of Yang pulses. Evil invading the Five Zang organs causes disharmony of the Yin pulses; disharmony of the Yin pulses causes Blood stagnation; Blood stagnation leads to an excess of Yin pulses. When Yin Qi is excessively excessive, Yang Qi cannot mutually nourish and harmonize, hence it is called "Ge" (Rebellion/Obstruction). When Yang Qi is excessively excessive, Yin Qi cannot mutually nourish and harmonize, hence it is called "Guan" (Closure). When both Yin and Yang Qi are excessive and cannot mutually nourish and harmonize, it is called Guan Ge. Those suffering from Guan Ge will die as their lifespan is exhausted. ○ A pulse extending to the fish border (Yuchi) is called Yi pulse, representing Wai Guan Nei Ge (External Closure Internal Rebellion). A pulse extending into the Chi position is called Fu pulse, representing Nei Guan Wai Ge (Internal Closure External Rebellion). (From *Nan Jing*)
[Philosophical Discourses]
The Cunkou pulse is floating and large; floating indicates deficiency, large indicates excess. When seen at the Chi position, it is Guan; when seen at the Cun position, it is Ge. Guan results in inability to urinate; Ge results in vomiting and reflux. ○ The Heart pulse is洪大 (Hongda/Vigorous and Large) and long; if the head is slightly small and the root large, sweating occurs; if the lower part is slightly large, Guan Ge obstruction occurs, and urination is impossible. If the head has no sweat, it is treatable; if there is sweat, it is fatal. ○ The Duyang pulse is Fu (Deep) and Se (Choppy); Fu indicates vomiting and reflux with undigested food and drink; Se indicates inability to swallow food, a condition named Guan Ge. (Zhang Zhongjing)
Guan refers to inability to urinate; Ge refers to vomiting and reflux. Guan is caused by extremely hot Qi causing blockage; Ge is caused by extremely cold Qi causing obstruction. Thus, Guan has no outlet, and Ge has no entry. Cold retained in the chest prevents entry; Heat accumulated in the Lower Jiao prevents exit. (Zhang Jiegu)
Guan Ge syndrome refers to a sensation of obstruction in the Diaphragm, where rising is impeded, descending is blocked, and appetite is lost. This is due to Qi transverse obstruction. (Dai Fuan)
Zoubu (Running Back/Nausea) arises from lower obstruction, with turbid Qi rushing upward, preventing food intake. Guan Ge arises from the inversion of Upper and Lower Yin and Yang Qi, where nothing can enter above and nothing can exit below. (*Yi Jie Bian Zheng*)
The term Guan Ge in *Nei Jing* originally referred to pulse morphology to illustrate the separation of Yin and Yang. Since Qin Yueren (Bian Que) interpreted Guan Ge using Cun and Chi positions, he deviated from the original meaning of the Classic. Furthermore, Zhang Zhongjing stated: Pulse at Chi is Guan (urinary retention); pulse at Cun is Ge (vomiting/reflux). Consequently, later physicians from Wang Shuhe and Li Dongyuan onwards transmitted this view, completely neglecting the true nature of Guan Ge syndrome. Later, Zhu Danxi claimed this syndrome is mostly fatal, attributing it to Cold above and Heat below, with both Cun pulses exceeding four times normal size, suggesting emesis to lift the transverse Qi. I argue that if both Cun pulses are four times larger, how can it be Cold above? Moreover, such a large pulse indicates floating, hollow, and rootless qualities, revealing severe deficiency; how can emesis be used? Error upon error, none is greater than this! The Renying and Cunkou mentioned in *Nei Jing* do not refer to Cun and Chi positions; vomiting specifically refers to Dysphagia (Yishi); urinary retention specifically refers to Long Bi (Strangury). These conditions have their own distinct categories and are unrelated to Guan Ge. If these masters erred, what of others? ○ *Nei Jing* states: Renying four times larger is Ge Yang; Cunkou four times larger is Guan Yin; both four times larger is Guan Ge. This definition of Guan Ge is based on pulse, not symptoms. Many people suffer from this now but do not recognize it; if both hands show floating, wiry, rapid, and large pulses (four times normal), it is this syndrome. Symptoms must include palpitation of Xuli (Vitalis) and incessant asthma; this asthma usually lacks cough, but feels like chest pounding, distension without fullness, shortness without suffocation, worsening with slight exertion or speech, even whole-body tremors and panic. This is likely due to emotional/lust injury causing rootless Yuan Qi and extreme separation of solitary Yang, mostly untreatable. (Zhang Jingyue)
Commentary: *Nei Jing* states Guan Ge when Renying and Cunkou are four times larger, determining Yang meridians by Renying and Yin meridians by Cunkou. Yueren said: Extending to Yuchi is Yi (Wai Guan Nei Ge); entering Chi is Fu (Nei Guan Wai Ge). Zhongjing also said: Chi is Guan (urinary retention); Cun is Ge (vomiting). These determine Yang by Cunkou and Yin by Chi. *Nan Jing* adds: Pulse above, no pulse below, expecting vomit but unable to vomit is fatal. Zhongjing added: Duyang Fu and Se indicates vomiting/undigested food (Fu) and inability to eat (Se), named Guan Ge. Thus, Guan Ge pulses/symptoms vary. Ma Zhonghua explained *Nei Jing*, stating Guan Ge is not Dysphagia or Strangury. Zhang Jiabin rejected Yueren and Zhongjing entirely, insisting Renying is on the neck (Yangming surface pulse), criticizing Dongyuan and Danxi for following Shuhe's left-right Renying/Qikou error. Alas! *Nei Jing* is sacred and should be followed, but Yueren and Zhongjing's works are also sacred. Renying/Qikou distinguish Surface/Interior Yin-Yang; Cunkou/Chi distinguish Upper/Lower Yin-Yang. Lung governs Qi transformation of Surface/Interior/Upper/Lower; Heart governs Blood vessels. Thus, Qi/Blood changes manifest at Qikou (Lung meridian pulse), merely differentiating locations to inspect other Zang. Just as Zhongjing uses Duyang/Shaoyin (foot pulses) inferred from Guan/Chi, interpreting Renying/Qikou at left/right is also acceptable. Therefore, explaining *Nei Jing*'s Guan Ge should only describe it as Surface/Interior Yin-Yang blockage/separation, not conflating it with Vomiting/Urinary Retention Guan Ge. However, calling Vomiting/Retention "Guan Ge" is incorrect; they should be named Dysphagia and Strangury. It is acceptable to say Guan Ge pulses may not always be so; it is unacceptable to say Guan Ge pulses never differentiate between Chi and Cun. (*Zhang Shi Yi Tong*)
Guan Ge is misunderstood by many, ignoring *Nei Jing*'s clear distinction of Renying/Cunkou. Renying governs Three Yang; Cunkou governs Three Yin. Three Yang are governed by Stomach; Three Yin by Lung. "Ge" implies obstruction; "Guan" implies closure. The Classic does not specify symptoms, making it hard to predict. Zhongjing clarified: Guan is urinary retention; Ge is vomiting. This makes it clear. Yangming Stomach receives food/water; if Three Yang are blocked at Yangming, how does food enter? Taiyin Spleen regulates waterways; if Three Yin are closed at Taiyin, how are waterways regulated? Treating without focusing on Lung/Stomach—whether assuming Yang inverted below/Yin above, or Yang blocking Yin/Yin rejecting Yang, or Yin-Yang non-interaction—is inaccurate. ○ Previous interpretations relied on Zhongjing, but his description is only one aspect of Guan Ge. Saying vomiting/retention is NOT Guan Ge is wrong; saying it EXHAUSTS all Guan Ge pathology is also wrong. Yin-Yang should be connected; Guan Ge isolates them. *Nei Jing* discusses pulse, not symptoms, implying broad scope. Thus, any condition where Yin-Yang ignore each other and symptoms appear separately belongs to Guan Ge category. ○ Treat Yin disease by saving Yin; Yang disease by saving Yang; both by saving both. If Yin-Yang are diseased and separate, how to handle? Thus, vomiting/retention is merely a precursor. Other examples: Gan Huoluan (Dry Cholera) wanting to vomit/diarrhea but unable, half-body cold/half-hot, or mixed Yin-Yang pathology—all are Guan Ge-like, but not True Guan Ge. True Guan Ge is incurable and fatal before expected term. (*Yi Can*)
[Supplement]
Although Guan Ge has varieties, it generally stems from Liver Qi Stagnation, as Liver governs free flow. Treatment uses Xiaoyao San, adding Zhizi and Cheqianzi to direct rebellious Qi downward, and Chaihu to raise Liver Qi depression, embodying Harmonizing method. (Chen Shiduo)
Guan Ge is an acute disease. Constipation, thirst, vomiting, dry lips, red face, deep-hidden pulse indicate Cold entering Shaoyin, Yin excess below forcing Yang above. Must use Baitong Tang, applying Cold with Heat method, mixing human urine and pig gallbladder bile (salty/bitter) into warm medicine to align Qi and remove obstructing Cold. Pulse gradually appearing indicates life; suddenly appearing indicates death. (*Zhao Shi Yi Guan*)
*Nei Jing* says: Long illness transforms, Upper/Lower do not interact, even good doctors fail. This refers to Guan Ge. "No interaction" means non-communication; Yang above cannot descend, Yin below cannot ascend, Heaven/Earth do not interact, and transformation mechanism stops. Descending Yang injures Yin; Ascending Yin damages Yang. Thus ancients prescribed formulas not treating Cold/Heat directly, but unblocking orifices. (*Jianwen Lu*)
Guan Ge severely damages the root; medication is essential. Essence deficiency requires tonifying essence; Qi deficiency requires benefiting Qi. However, one must live apart, cultivate mind and body quietly over years to preserve health. Without cutting off worldly affairs, relying solely on medicine is futile. (Zhang Jingyue)
Guan Ge is discussed deeply in *Ling Shu*, *Su Wen*, *Nan Jing*, and Zhongjing's pulse methods, yet no specific formula exists. Later generations, lacking established formulas, ignored profound meanings, keeping only the name. Yun Qizi described Yin-Yang reversal and transmitted nine tested formulas. He stated Yin-Yang position swap is Guan Ge: Upper chest Yang constant = Heat dominant; Lower body Yin constant = Cold dominant. Chest Cold treated with Hot meds; Dantian Heat treated with Cold meds. Mixed Cold/Heat in chest uses Master/Guest method. Slow treatment for Master, urgent for Guest. This derives from *Shang Han Lun* (Chest Cold/Dantian Heat) but is not true Guan Ge. Its reference to *Nei Jing* luck/master-guest methods is baseless. It ignores *Ling/Su/Nan/Jin Gui* texts, incorporating poor later formulas. Minor flaws: mixing Er Chen, Wu Ling, Zhi Ke, Hou Po, Bing Lang, Mu Xiang. Major flaws: mixing Bing Pian, She Xiang, Fu Zi, Zao Jiao, Qian Niu, Da Huang, Xiao Ming. Can Yin-Yang imbalance be treated by claiming Yin above/Yang below? Can a near-fatal case be treated with coercive methods seizing Yin-Yang? Zhongjing used Duyang pulse to guide regulating Ying-Wei, avoiding Yin/Yang bias, allowing Stomach Qi to distribute naturally for balance. This is not achieved instantly. Thus, regardless of where Guan/Ge opens/closes, seek resolution in the Middle, grasp the pivot, and operate. Treat Ge (vomiting) by penetrating upward from Middle; treat Guan (retention) by penetrating downward from Middle; treat both by penetrating up/down from Middle. Tentatively establish Jin Tui Huang Lian Tang. This is insufficient for those on the right path. ○ Huang Lian Tang is Zhongjing's Shang Han formula. Stomach evil blocks Yin-Yang升降 (ascending/descending) at Middle Earth, causing Yin to stay below (Cold abdomen/pain) and Yang to stay above (Hot chest/vomiting). This formula regulates Yin-Yang. But why use it for dampness patients misused purgatives with tongue coating, Dantian heat/chest cold? Shang Han treats Surface/Interior/Middle. When Surface/Interior evil are strong, harmonize from Middle (Xiao Chai Hu Tang). Medicine enters Stomach; ascending Qi carries Chai Hu out (Surface); descending Qi carries Huang Qin in (Interior). One harmonization clears Surface/Interior without conflict. For Dantian/Chest evil (Upper/Lower, not Surface/Interior), change Chai Hu Tang to Huang Lian Tang to harmonize Upper/Lower. Medicine enters Stomach; Qi distributes up/down. Thus, Upper Heat/Lower Cold or vice versa are treatable. Surface/Interior evil use Chai Hu/Huang Qin; Upper/Lower evil use Gui Zhi/Huang Lian. Surface/Interior use Sheng Jiang to disperse; Upper/Lower use Gan Jiang to open. Zhongjing's holy method is clear. I propose adjusting Upper/Lower methods via Middle, grasping pivot, penetrating up/down. For Ge (vomiting), advance with this formula. Taiyang governs opening; if Taiyang fails to open, chest stuffiness prevents eating/ejection. Gui Zhi (Taiyang herb) harmonizes Ying-Wei, moves Yang Dao, thus opens. However, if Five Emotions/Jue Yang Fire rise, Gui Zhi is contraindicated (adding fire to fire, head sweat, Yang collapse). For Guan (retention), retreat method penetrates Yin via Stomach Qi; Gui Zhi is excluded. But Stomach gate is closed; Shaoyin governs closing; if Shaoyin Qi doesn't ascend, Stomach gate won't open. *Nei Jing*: Kidney Qi sinks alone; Kidney Qi unbalanced. True Qi in Kidney is like a scale; with weight and beam, gate opens/closes. With weight but no beam, gate only closes, no urine. Thus, Shen Qi Wan is necessary in retreat. Kidney Qi interacting with Stomach opens gate; interacting with Heart subdues Jue Yang Fire. There are times for its use. ○ Treating Guan Ge without guiding/directing, hoping only to stop vomiting/diurese, urgently treating branch, exhausting skill, harming patient, is doctor's fault. ○ Treating Guan Ge ignoring Renying/Duyang/Taichong, holding only Cunkou, is negligence. Ignoring Cunkou Yin-Yang differentiation is doctor's fault. ○ Not distinguishing Pulse Yang Deficiency/Excess, Yin Deficiency/Excess to adjust treatment, like blind man walking, is doctor's fault. ○ Treating Guan Ge not via Kingly Way but Hegemonic Methods, showing off skill, hastening death, is doctor's fault. (*Yi Men Fa Lv*)
[Attached Formulas]
**Jin Tui Huang Lian Tang (Advance-Retreat Coptis Decoction)**
Huang Lian (Stir-fried with Ginger Juice) 1.5 qian; Gan Jiang (Roasted) 1.5 qian; Ren Shen (Steamed with Human Milk) 1.5 qian; Gui Zhi 1 qian; Ban Xia (Processed with Ginger) 1.5 qian; Da Zao 2 pieces.
Advance Method: Use all six ingredients unprocessed. Water 3 tea cups, decoct to 1.5 cups, take warm.
Retreat Method: Omit Gui Zhi, halve Huang Lian, or add Rou Gui 0.5 qian. Process ingredients thoroughly as above, decoct and take same as above.
Take Ba Wei Wan 3 qian in morning, take decoction when half-hungry.
**Zi Ye Jiao Fen Tang (Fluid-Nourishing Fire-Saving Decoction)**
Treats Five Emotions Jue Yang Fire.
Sheng Di Huang (Juice) 2 qian; Mai Men Dong (Juice) 2 qian; Ren Shen (Steamed with Human Milk) 1.5 qian; Hu Ma Ren (Stir-fried & ground) 1 qian; Bai Zi Ren (Stir-fried) 0.7 fen; Gan Cao (Roasted) 1 qian; Wu Wei Zi 0.4 fen; Zi Shi Ying (Crushed) 1 qian; E Jiao 1 qian; Han Shui Shi (Crushed) 1 qian; Hua Shi (Crushed) 1 qian; Xi Jiao (Ground juice) 0.3 fen; Sheng Jiang Jiang (Ginger Juice) 3 spoons.
Except for the four juices and E Jiao, decoct the other eight ingredients in 4 tea cups of water with slow fire to 1.5 cups. Remove dregs, add four juices and E Jiao, decoct until E Jiao melts. Pour out, mix in Niu Huang 0.05 fen. Take hot, divided into 2-3 doses during midday. Take Ba Wei Wan 3 qian on empty stomach in morning.