灵枢云。阴气太盛。则阳气不能营也。故曰关。阳气太盛。则阴气弗能营也。故曰格。阴阳
俱盛。不得相营。故曰关格。关
格者。不得尽期而死也。
阴阳易位。病名关格。多不可治。若邪气留着而致者。犹可治之。舌上苔白而水浆不下曰格。
格则吐逆。热在丹田。小便不过曰关。关则不得小便。必用吐以提其气之捍格。不必在出痰也。
盐汤探吐。并以牙皂汤浴其小腹及阴。或以盐熨脐中俱妙。有痰宜吐者。二陈汤探吐之。吐中便
有升降。有中气虚不运者。补气药中升降。先以四君子换参芦探吐。后用人参散、柏子仁汤调理。
脉沉细。手足厥冷者。既济丸。劳役后气虚不运者。补中益气汤加木香、槟榔。心脾疼后。小便
不通。皆是痰隔于中焦。气滞于下焦。二陈加木通、枳壳。服后探吐之。寒在上。热在下。黄连
汤。桂枝易肉桂。热在上。寒在下。生料八味丸。加牛膝、车前。关格不通。不得尿。头无汗者
可治。有汗者死。
石顽曰。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。遂上鱼为溢。为外关内格。遂入尺为覆。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。所以难经又言上
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。
而张介宾类经。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。
未常不为圣经也。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。医道贵乎圆通。若
执中无权。犹执一也。故释内经之关格。但当言是表里阴阳否绝之候。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。试观仲景趺阳脉伏而涩。亦主关格。又有上
微头小者。则汗出。下微本大者。则为关格不通等例。其义自明。
《灵枢》说：阴气过于旺盛，阳气就无法在其中运行，所以称为“关”。阳气过于旺盛，阴气就无法在其中运行，所以称为“格”。阴阳二气都过于旺盛，彼此不能相互协调运行，所以称为“关格”。患有关格病的人，往往活不到预定的寿命就会死亡。
阴阳位置发生颠倒，这种病症叫做关格，大多难以治愈。如果是由于邪气滞留体内所导致的，还可以治疗。舌苔白腻且无法进食进水，这叫做“格”，格则会出现呕吐逆乱的症状。热邪积聚在下焦丹田，小便不通畅，这叫做“关”，关则会导致无法排尿。此时必须使用催吐的方法来提举上逆之气以解除阻滞，不一定非要吐出痰液不可。可以用盐汤探引催吐，并用牙皂汤洗浴其小腹及外阴部位，或者用盐炒热熨烫脐中，这些方法都很妙。如果有痰湿适宜催吐的，可用二陈汤探引催吐。在催吐的过程中本身就包含了气机升降的道理。对于中气虚弱、运化无力者，可在补气药中加入升降气机的药物；先用四君子汤替换人参芦头进行探引催吐，之后再用参散、柏子仁汤进行调理。
如果脉象沉细，手足厥冷，适用既济丸。如果是劳累后气虚导致气机不运，适用补中益气汤加木香、槟榔。在心脾疼痛之后出现小便不通，这都是因为痰浊阻隔在中焦，气机停滞在下焦所致，可用二陈汤加木通、枳壳，服药后再进行探引催吐。寒邪在上焦，热邪在下焦，适用黄连汤（将桂枝换为肉桂）。热邪在上焦，寒邪在下焦，适用生料八味丸加牛膝、车前子。关格导致小便不通，如果头部没有汗出，尚可治疗；如果头部有汗出的，预后不良，主死。
石顽说：按照《内经》所说，人迎脉与寸口脉都盛大四倍以上，这就是关格。这是阳经的病证取决于人迎脉，阴经的病证取决于寸口脉。《难经》说：脉气向上延伸至鱼际以上，称为溢脉，表现为外关内格；脉气向下延伸至尺部以下，称为覆脉，表现为内关外格。张仲景也说，脉象在尺部表现为关，在寸部表现为格。关则小便不通，格则呕吐逆乱，这些都是以阳分病证取决于寸口，阴分病证取决于尺内。所以《难经》又说，上部有脉，下部无脉，病人应当呕吐，如果不呕吐的，就会死亡。张仲景又有趺阳脉伏而涩的描述，伏脉则导致呕吐逆乱，水谷不化；涩脉则导致食物无法进入，这叫做关格。由此可知，关格的脉证并不单一。马仲化解释《内经》时认为，关格的含义，并非指隔食和癃闭这类病症。而张介宾在《类经》中，直接将越人（扁鹊）和张仲景的说法一概否定，独自坚持人迎穴在颈部，是阳明经的表脉，从而诋毁李东垣和朱丹溪，他们仍然沿用王叔和《脉经》中左为人迎、右为气口的错误观点。唉！《内经》固然被视为经典，确实应当遵从，但越人和张仲景的著作，也未尝不能视为经典。大概人迎和气口，是用来区分表里之阴阳的；寸口和尺内，是用来区分上下之阴阳的。人体一身表里上下的气化功能，都由肺所主管，血脉都由心所主宰。所以凡是气血的盛衰，无不反映在气口脉上。气口实际上是肺经的一条脉，只是通过划分不同部位，来诊察其他脏腑的气机罢了。就像张仲景所指出的，趺阳脉和少阴脉虽然主要对应足部经脉，但也未尝不能在关部和尺部推演。那么《内经》所说的人迎、气口，在左右两侧进行诊察，也是可以的。医学之道贵在圆融通达，如果执守中道却不知权变，就如同固执一端一样。因此，解释《内经》中的关格，只应当说是表里阴阳隔绝断绝的征候，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，应当称为隔食癃闭，不能命名为关格，这是不对的。或者说关格这种病症，其脉象未必都是如此，这是可以的；如果说关格的脉象，必然没有在尺部和寸部的区别，这是不对的。试看张仲景提到的趺阳脉伏而涩，也主关格；又有脉象上部微细头部小者，则会汗出；下部微细根本大者，则为关格不通等例子，其中的道理自然明了。
The *Ling Shu* (Spiritual Pivot) states: When Yin Qi is excessively abundant, Yang Qi cannot circulate within it; this is called "Guan" (Obstruction). When Yang Qi is excessively abundant, Yin Qi cannot circulate within it; this is called "Ge" (Rejection). When both Yin and Yang Qi are excessively abundant and cannot mutually coordinate their circulation, this is called "Guan Ge" (Obstruction and Rejection). Patients suffering from Guan Ge often die before their natural lifespan is exhausted.
When the positions of Yin and Yang are reversed, the disease is named Guan Ge, which is mostly incurable. However, if it is caused by the lingering of pathogenic factors, it may still be treatable. A white coating on the tongue accompanied by the inability to swallow food or fluids is termed "Ge"; Ge manifests as vomiting and regurgitation. Heat accumulating in the Dantian (Lower Abdomen) with an inability to urinate is termed "Guan"; Guan results in urinary retention. In such cases, inducing vomiting must be used to lift the stagnant Qi and resolve the obstruction, regardless of whether phlegm is expelled. Salt water can be used to induce vomiting, and a decoction of *Adansonia digitata* seed powder (Ya Zao Tang) can be used to bathe the lower abdomen and genitals. Alternatively, applying hot salt to the umbilicus is also excellent. If phlegm-dampness is present and vomiting is indicated, *Er Chen Tang* (Two-Cured Decoction) can be used to induce vomiting. The process of vomiting inherently involves the regulation of Qi ascent and descent. For patients with deficiency of Middle Qi leading to poor transportation, Qi-tonifying herbs should be combined with agents that regulate Qi movement. First, use *Si Jun Zi Tang* (Four Gentlemen Decoction) replacing Ren Shen (Ginseng Root) with Ren Shen Lu (Ginseng Stalk) to induce vomiting, followed by regulation using *Ren Shen San* (Ginseng Powder) and *Bai Zi Ren Tang* (Biota Seed Decoction).
If the pulse is deep and fine, with cold extremities, *Ji Ji Wan* (Already Interpenetrating Pill) is indicated. If Qi deficiency after overwork leads to poor Qi movement, *Bu Zhong Yi Qi Tang* (Tonify the Middle and Augment the Qi Decoction) added with Mu Xiang (Aucklandiae Radix) and Bing Lang (Arecae Semen) is indicated. After heart-spleen pain, if urinary retention occurs, it is due to phlegm obstructing the Middle Jiao and Qi stagnation in the Lower Jiao. Use *Er Chen Tang* added with Mu Tong (Akebiae Caulis) and Zhi Ke (Aurantii Fructus), followed by induced vomiting after administration. For cold in the Upper Jiao and heat in the Lower Jiao, *Huang Lian Tang* (Coptis Decoction) is used, substituting Gui Zhi (Cinnamon Twig) with Rou Gui (Cinnamon Bark). For heat in the Upper Jiao and cold in the Lower Jiao, *Sheng Liao Ba Wei Wan* (Raw-Ingredient Eight-Ingredient Pill) added with Niu Xi (Achyranthis Bidentatae Radix) and Che Qian (Plantaginis Semen) is indicated. In Guan Ge with urinary retention, if there is no sweat on the head, the condition is treatable; if there is sweat on the head, it indicates death.
Shi Wen stated: According to the *Nei Jing* (Inner Canon), when both the Ren Ying pulse (carotid artery) and Cun Kou pulse (radial artery) are four times larger than normal, this constitutes Guan Ge. This implies that Yang meridians are determined by the Ren Ying pulse, and Yin meridians by the Cun Kou pulse. The *Nan Jing* (Classic of Difficult Issues) states: Pulse qi extending upward beyond the大鱼际 (Thenar eminence) is called "Yi" (Overflow), manifesting as external Guan and internal Ge. Pulse qi extending downward beyond the Chi position is called "Fu" (Cover), manifesting as internal Guan and external Ge. Zhang Zhongjing also stated that pulse at the Chi position indicates Guan, and at the Cun position indicates Ge. Guan results in urinary retention, and Ge results in vomiting and regurgitation. These views determine Yang aspects by the Cun Kou pulse and Yin aspects by the Chi position. Thus, the *Nan Jing* further states: If there is a pulse in the upper part but none in the lower part, the patient should vomit; if they do not vomit, they will die. Zhang Zhongjing also described the Fu Yang pulse (dorsalis pedis artery) as deep and choppy; a deep pulse leads to vomiting and regurgitation with undigested food and drink, while a choppy pulse prevents food intake; this is named Guan Ge. From this, we know that the pulse and symptoms of Guan Ge are not uniform. Ma Zhonghua, in his explanation of the *Nei Jing*, argued that the meaning of Guan Ge does not refer to conditions like food blockage or urinary retention. However, Zhang Jiebin, in his *Lei Jing* (Classified Classic), directly refuted the statements of Bian Que (Yue Ren) and Zhang Zhongjing, insisting solely that the Ren Ying point is located in the neck and represents the exterior pulse of the Yangming Meridian. He thereby criticized Li Dongyuan and Zhu Danxi for adhering to the erroneous view in Wang Shuhe's *Mai Jing* (Pulse Classic) that the left side is Ren Ying and the right side is Qi Kou. Alas! While the *Nei Jing* is undoubtedly a sacred text that must be followed, the works of Yue Ren and Zhang Zhongjing are also worthy of being considered sacred texts. Generally, Ren Ying and Qi Kou are used to distinguish the Yin-Yang of the interior and exterior, while Cun Kou and Chi are used to distinguish the Yin-Yang of the upper and lower parts. The Qi transformation of the entire body's interior, exterior, upper, and lower regions is governed by the Lung, and blood vessels are controlled by the Heart. Therefore, any changes in the abundance or deficiency of Qi and Blood inevitably manifest in the Qi Kou pulse. Qi Kou is essentially a pulse of the Lung Meridian, merely divided into different locations to observe the Qi of other Zang-Fu organs. Just as Zhang Zhongjing pointed out, although the Fu Yang and Shao Yin pulses primarily correspond to the foot, they can also be deduced from the Guan and Chi positions. Therefore, observing Ren Ying and Qi Kou on the left and right sides as described in the *Nei Jing* is also acceptable. Medical practice values flexibility and comprehensiveness; if one holds to the mean without knowing how to adapt to circumstances, it is akin to sticking rigidly to one side. Thus, when explaining Guan Ge in the *Nei Jing*, one should only describe it as a sign of the severance of Yin-Yang between the interior and exterior, and should not conflate it with the Guan Ge characterized by upper vomiting and lower closure. It is incorrect to claim that upper vomiting and lower closure should be called food blockage and urinary retention and not Guan Ge. It is acceptable to say that the pulse in Guan Ge cases may not always be uniform; however, it is incorrect to claim that Guan Ge pulses necessarily lack differentiation between the Chi and Cun positions. Consider Zhang Zhongjing's mention that a deep and choppy Fu Yang pulse also governs Guan Ge, or examples where a faint upper pulse with a small head indicates sweating, and a faint lower pulse with a large root indicates Guan Ge obstruction. The principles are clear in these instances.