关格一症。上则格而不入。下则闭而不通。乃阴阳偏胜之候。亦阴阳离绝
之证也。阳偏胜则上逆。逆之久则阴从之。上逆故水浆不受。烦躁不宁。阴
从之故出而不返。有升无降。阴阳于是乎离绝。头汗出而四肢冷。脉无而
死矣。不然。丹溪谓上窍通。则下窍之水出焉。此何以上愈通而下愈不出
也。然素问云。无阳则阴无以生。无阴则阳无以化。今阳偏胜而阴往从之。
则有阳无阴。灼然可知。经又曰。上焦主纳。下焦主出。又曰三焦者。决渎之
官。水道出焉。今上不纳而下不出。则三焦之火竭尽无余。求其头无汗而
阳不上越。肢不冷而阴不下绝。其可得乎。扁鹊谓不得尽其命而死。后肾
谓九死一生之候。诚难乎其为治矣。余独思阴绝阳绝。诚不可疗。使当其
未竭绝之际。而欲得一挽回之法。非上有以回其阳。下有以挽其阴。乌克
有济。因悟仲景白通汤。用姜附纯阳之药。恐其阳上绝。而以人尿猪胆纯
阴之味引之。恐其阴下绝。使阴阳协于和而后已。斯则治法之善者也。及
节庵扩而充之。立回阳返本汤。亦阴阳相济欲底于平。加黄连腊茶以降
火。姜附为反佐。而以人参五味复其津液元气。使不致于离绝。则又法外
之法也。嘉言出。立黄连进退汤。酌其阴阳之偏。而进退补救之。又从事于
八味汤。复其阴阳之根。以立其命。可谓思穷而路绝矣。学人诚于此而会
通焉。则关格一症。庶乎出万死于一生。济无穷之夭枉矣。
按格之吐逆。与凡吐逆之不同。盖凡吐逆则小便利。阳气得以下荣。阴
气尚能留恋。则不至于上脱矣。关之小便不通。与凡小便不通之不同。
盖凡小便不利。则上不吐逆。阴气纵不能化。阳气尚未离绝。则不至于
下脱矣。惟格则阴绝于上。故投热药而弥炽。须以阴药济之。则不捍格。
关则阳绝于下。故投阴药而厥逆。须以阳药挽之。则能气化。此阴阳俱
病。须以阴阳相济之药救之。乃玄妙之门也。试验小便不通。必小腹胀
闷不堪。惟关症则但有急而欲解之状。未尝胀闷。可知阳气耗而阴气
并为之竭矣。此时呕逆甚而胸满或痛。亦阴气上窜之故。初非有实邪
也。且肾主二便。又主水火。今气不下纳。根将绝矣。八味丸导火归元。而
能复真阴。非又要着也哉。
黄连进退汤
川黄连（姜汁炒） 炮姜 半夏 川牛膝（盐水炒） 白芍（酒炒各一钱） 人参（钱半） 大枣肉（三枚） 童
便（小半杯）
水煎。如阳虚肢冷。加熟附子一钱。减连五分。阴虚躁渴。加麦门冬一钱。去半夏。
白通汤
葱白（二茎） 熟附子（三钱） 干姜（钱半）
水煎。加人尿猪胆汁。
回阳返本汤（见阴症论）
关格这一病症，上部表现为格拒而饮食无法进入，下部表现为闭塞而二便不通。这是阴阳偏盛的表现，也是阴阳离绝的证候。阳气偏胜则向上逆乱，逆乱日久则阴气随之而上。因为上逆，所以水浆不能受纳；因为烦躁不安、心神不宁；阴气随之而上，所以有出无入，只有升没有降。于是阴阳就此离绝。出现头部出汗而四肢冰冷，脉象消失，病人就会死亡。
如果不是这样，朱丹溪曾说：“上窍通畅，那么下窍的水液就能排出。”为什么这里上面越通畅，下面却越排不出呢？然而《素问》说：“没有阳，阴就无法生成；没有阴，阳就无法化生。”现在阳气偏胜而阴气去追随它，这就变成了有阳无阴，这是显而易见的。医经又说：“上焦主管受纳，下焦主管排泄。”又说：“三焦是决渎之官，水道由此而出。”现在上面不能受纳，下面不能排泄，那么三焦之火已经枯竭殆尽。想要做到头部不出汗而阳气不上越，四肢不冷而阴气不下绝，怎么可能呢？扁鹊说，这种情况会导致病人不能尽其天年而死；后世肾家（指重视肾脏理论的医家）称之为九死一生的证候，确实很难治疗啊。
我独自思考，阴绝和阳绝，确实难以治愈。如果在它们尚未完全枯竭离绝的时候，想要找到一种挽回的方法，不是在上部能够回阳，在下部能够挽阴，怎么会有帮助呢？因此我领悟到张仲景的白通汤，使用干姜、附子这些纯阳的药物，恐怕阳气在上部绝灭，所以用人尿、猪胆汁这些纯阴的味道来引导它，防止阴气在下部绝灭，使阴阳协调和谐才停止。这是很好的治疗方法。到了节庵（薛己的字）将其扩充完善，创立了回阳返本汤，也是通过阴阳相互济助来达到平衡。加入黄连、腊茶来降火，用姜、附作为反佐，并用的人参、五味子来恢复津液元气，使其不至于离绝，这又是法外之法。嘉言（姚际盛的号）出现后，创立了黄连进退汤，斟酌阴阳的偏颇，进行进退补救。又从事于八味丸（金匮肾气丸），恢复阴阳的根本，以确立生命。可以说思虑已穷尽，路子似乎走绝了。学习者如果能在此处融会贯通，那么对于关格这一病症，或许能从万死中求得一生，救济无数夭折枉死者。
按：格证的呕吐逆乱，与一般的呕吐逆乱不同。一般来说，呕吐逆乱时小便仍然通畅，阳气得以向下荣养，阴气尚能留恋，就不会发生上部脱绝。关证的小便不通，与一般的小便不通不同。一般来说，小便不利时，上部不会呕吐逆乱，阴气纵然不能化生，阳气尚未离绝，就不会发生下部脱绝。只有格证是阴绝于上，所以投用热药反而更加炽烈，必须用阴药来济助，才不会格拒。只有关证是阳绝于下，所以投用阴药反而导致厥逆，必须用阳药来挽回，才能气化。这是阴阳俱病，必须用阴阳相济的药物来救治，这才是玄妙之门。
试验观察小便不通的病人，必然小腹胀闷不堪忍受。只有关证只是有急切想要解手的感觉，从未感到胀闷。可知阳气耗散而阴气也随之枯竭。此时呕吐逆乱严重且胸部满闷或疼痛，也是阴气上窜的缘故。起初并不是有实邪存在。而且肾主管二便，又主管水火。现在气不能下行纳藏，根将绝灭。八味丸能导火归元，从而恢复真阴，这不又是关键之处吗？
黄连进退汤
川黄连（姜汁炒） 炮姜 半夏 川牛膝（盐水炒） 白芍（酒炒各一钱） 人参（钱半） 大枣肉（三枚） 童便（小半杯）
水煎服。如果阳虚四肢冷，加熟附子一钱，减黄连五分。如果阴虚躁渴，加麦门冬一钱，去掉半夏。
Guan-ge (Obstruction and Rejection) is a syndrome where the upper part manifests as rejection, preventing food and drink from entering, while the lower part manifests as closure, blocking the excretion of urine and feces. This is a sign of Yin-Yang imbalance with excess in one aspect, and also a syndrome of Yin-Yang separation and extinction. When Yang is in excess, it rebels upward; after prolonged rebellion, Yin follows it upward. Due to this upward rebellion, fluids cannot be accepted; due to restlessness and agitation, there is only egress without ingress, only ascending without descending. Thus, Yin and Yang separate and extinguish. The patient presents with sweating on the head and coldness in the four limbs, the pulse disappears, and death ensues.
If this were not the case, Zhu Danxi stated: "When the upper orifices are open, the water from the lower orifices will flow out." Why then, when the upper part is more open, does the lower part fail to discharge? However, *Suwen* states: "Without Yang, Yin cannot be generated; without Yin, Yang cannot be transformed." Now, since Yang is in excess and Yin follows it, there is Yang without Yin, which is evident. The classics further state: "The Upper Jiao governs reception, and the Lower Jiao governs excretion." It also says: "The Sanjiao is the official of drainage, through which water passages flow." Now, since the upper part fails to receive and the lower part fails to excrete, the fire of the Sanjiao is completely exhausted. How could it be possible for the head not to sweat while Yang does not rebel upward, and for the limbs not to be cold while Yin does not descend into extinction? Bian Que said that such conditions lead to death before one's natural lifespan is fulfilled; later kidney-focused physicians described it as a condition with nine deaths to one survival, making treatment indeed difficult.
I alone pondered that Yin-extinction and Yang-extinction are indeed incurable. However, if one seeks a method of rescue before they are completely exhausted, unless there is a way to restore Yang above and retrieve Yin below, how can there be any benefit? Thus, I realized that Zhang Zhongjing's Baitong Decoction uses purely Yang herbs like Shengjiang (Dried Ginger) and Fuzi (Prepared Aconite Root). Fearing that Yang might extinguish at the top, it employs purely Yin substances like Renao (Human Urine) and Zhudanshi (Pig Gallbladder Stone/Bile) to guide it, fearing that Yin might extinguish at the bottom, so that Yin and Yang may coordinate and harmonize. This is an excellent therapeutic method. Later, Xue Ji (Zijie'an) expanded upon this and established Huiyang Fanben Decoction, also aiming for balance through mutual assistance of Yin and Yang. It adds Huanglian (Coptis Rhizome) and Laccha (Aged Tea) to clear heat, uses Jiang (Ginger) and Fu (Aconite) as counter-agents, and employs Renshen (Ginseng Radix) and Wuweizi (Schisandra Fruit) to restore body fluids and Yuan Qi, preventing separation and extinction. This is a method beyond methods. When Yao Jisheng (Jiayan) appeared, he established Huanglian Tuijin Decoction, adjusting for the bias of Yin and Yang through advancement and retreat. He also utilized Shiwu Wan (Eight-Ingredient Pill with Rehmannia) to restore the root of Yin and Yang, thereby establishing life. One might say that thought has reached its limit and the path seems closed. If students can integrate and understand this, then for the syndrome of Guan-ge, perhaps one can emerge from ten thousand deaths to find one life, saving countless premature deaths.
Note: The vomiting and rebellion of Ge syndrome differ from ordinary vomiting and rebellion. Generally, in ordinary vomiting and rebellion, urination remains smooth, allowing Yang Qi to nourish downward, and Yin Qi remains attached, preventing upper collapse. The urinary blockage of Guan syndrome differs from ordinary urinary difficulty. Generally, in ordinary urinary difficulty, there is no upper vomiting and rebellion; even if Yin Qi cannot transform, Yang Qi has not yet separated, preventing lower collapse. Only in Ge syndrome is Yin extinct at the top, so administering hot herbs makes the heat more intense; one must use Yin herbs to assist it to avoid rejection. Only in Guan syndrome is Yang extinct at the bottom, so administering Yin herbs leads to cold extremities; one must use Yang herbs to retrieve it to restore Qi transformation. This is a disease of both Yin and Yang, requiring herbs that mutually assist Yin and Yang for rescue, which is the profound gate.
Clinical observation shows that patients with urinary blockage invariably suffer unbearable abdominal distension and fullness. In Guan syndrome, however, there is only an urgent sensation of needing to void, without distension or fullness. This indicates that Yang Qi is depleted and Yin Qi is simultaneously exhausted. At this time, severe vomiting and rebellion accompanied by chest fullness or pain occur due to the upward rushing of Yin Qi. Initially, there is no excess pathogenic factor. Furthermore, the Kidney governs the two lower orifices and manages Water and Fire. Now, Qi fails to descend and be stored, and the root is about to extinguish. Shiwu Wan guides the floating fire back to its source and restores True Yin; is this not another crucial point?
Huanglian Tuijin Decoction
Chuan Huanglian (Stir-fried with Ginger Juice), Paojiang (Prepared Ginger), Banxia (Pinellia Tuber), Chuan Niuxi (Cyathulae Radix stir-fried with Salt Water), Baishao (White Peony Root stir-fried with Wine, each 1 qian), Renshen (Ginseng Radix, 1.5 qian), Dazao Rou (Date Flesh, 3 pieces), Tongbian (Child's Urine, half small cup).
Decoct in water. If Yang deficiency with cold limbs, add Shufuzi (Prepared Aconite Root) 1 qian, reduce Huanglian by 0.5 qian. If Yin deficiency with restlessness and thirst, add Maimendong (Ophiopogon Tuber) 1 qian, remove Banxia.
Baitong Decoction
Congbai (Scallion White, 2 stems), Shufuzi (Prepared Aconite Root, 3 qian), Ganjiang (Dried Ginger, 1.5 qian).
Decoct in water, add Renao (Human Urine) and Zhudanche (Pig Gallbladder Bile).
Huiyang Fanben Decoction (See Yin Syndrome Treatise)