关者不得小便，格者吐逆，上下俱病者也。格则吐逆。九窍、五脏、阴极自地
而升，是行阳道，乃东方之气，金石之变，上壅是也。极则阳道不行，反闭于上，
故令人吐逆，是地之气不能上行也。逆而下降，反行阴道，故气填塞而不入，则气
口之脉大四倍于人迎，此清气反行浊道也，故曰格。关则不便。下窍、六腑、阳极
自天而降，是行阴道，乃西方之气，膏粱之物，下泄是也。极则阴道不行，反闭于
下，故不得小便，是天之气不得下通也。逆而上行，反行阳道，故血脉凝滞而不通，
则人迎之脉大四倍干气口，此浊气反行清道也，故曰关。或问关格之病因何如？曰
《内经》以脏腑阴阳之病，诊见于外者，则在人迎气口，谓人迎一盛病在少阳，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。关格之脉赢，
不能极于天地之精气则死矣。注谓格者阳盛之极，故格拒而食不得入也。关者阴盛
之极，故关闭而溲不通也。《灵枢》亦尝三言之，其二者，皆如《内经》之论人迎气
口之盛分经脉也。但更谓盛者是足经，盛而躁者是手经。至人迎四盛，且大且数，
名曰溢阳，溢阳为外格。手太阴脉口四盛，且大且数，名曰溢阴，溢阴为内关。内
关不通，死不治。人迎与太阴脉口俱盛四倍以上，命曰关格，关格者与之短期。而
人迎与脉口俱盛三倍以上，命曰阴阳俱溢，如是不开，则血脉闭塞，气无所行，流
淫于中，五脏内伤矣。凡刺之道，从所分人迎一盛、三盛、五盛泻其阳，补其所合
之阴，二泻一补；寸口亦然，分泻其阴，补其所合之阳，二补一泻，皆以上气
和乃止。其一言邪在腑则阳脉不和，阳脉不和则气留之，气留之则阳气盛矣。阳气
太盛则阴不利，阴脉不利则血留之，血留之则阴气盛矣。阴气太盛则阳气不能荣也，
故曰关。阳气太盛则阴气不能荣也，故曰格。阴阳俱盛不得相荣也，故曰关格。关
格者，不得尽期而死也。由此而观，前之论人迎寸口者，为人迎主外，气口主内，故
分三阴三阳，气之多寡，定一盛二盛三盛而言也。若此之不言人迎寸口者，殆亦有
谓焉。何则？此因论脉度及之，而以手足十二经周行上下者，是大经隧，然一阴一
阳经相为脏腑之表里者，即有支横之路，通其内外，脏腑阴阳之气与之相荣，
故在两手寸关尺六部以为诊法。浮则为腑，沉则为脏者，于阴阳之盛，岂尽从其部
而见耶，故不复言人迎气口耳，及张仲景之言关格者，则可见矣。如谓寸口脉浮而
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。又谓心脉
洪大而长，是心之本脉也。上微头小者，则汗出，下微本大者，则为关格不通，不得
尿。头无汗者可治，有汗者死。又云∶趺阳脉伏而涩，伏则吐逆，水谷不化，涩则
食不得入，名曰关格。盖胃者水谷之海，营之居也。营者营卫之根源，营之机不动，
则卫气不布，卫气不布则脉伏，伏则谷不化而吐逆，荣气不行则脉涩，涩则食不入，如
是皆为外格，未见内关之病，亦通言为关格矣。注乃又以涩脉为脾病，且脾者阴
脏也。脾病则阴盛，阴盛当为内关，岂以外格其饮食不入耶。盖关格之名义，格者
拒捍其外，入者不得内。关者闭塞其内，出者不得泄。岂不明且尽乎。后世妄以小
便不通为格，大便不通为关，泛指在下阴阳二窍者为言，及乎阴阳之大法者，不复
穷已，抑非独此也。复有以阴阳格绝之证，通为关格之病者，是非错乱，有可叹焉。
夫隔绝之证，具于《内经》者，有曰隔则闭绝，上下不通者，暴忧之病也。注云∶
忧愁则气闭塞不行，血脉断绝，故大小便不得通。有曰病久则传化之行上下不并，
良医勿为。又有三阳结谓之隔。注云∶小肠膀胱热结也，小肠热结则血脉燥，膀胱
热结则津液涸，故隔塞而不便。又谓三阳积则九窍皆塞。又谓阳蓄积病死而阳
气当隔，隔者当泻，不亟正治，粗乃败之。原此数条，其与关格果何如耶。丹溪书
云∶必用吐，提其气之横格，不必在出痰也。又云∶有痰二陈汤吐之，吐中便有降。
中气不运者，补气药中升降，此盖窃其治小便之法填于条下，蹈世俗之弊而不悟，
悲夫。又考之王氏《脉经》，从八十一难谓∶有太过，有不及，有阴阳相乘，有覆有
溢，有关有格。然关之前者，阳之动也，脉当见九分而浮，过者、法曰太过，减者、
法曰不及。遂上鱼为溢，为外关内格，此阴乘之脉也。关以后者，阴之动也，脉当
见一寸而沉，过者、法曰太过，减者、法曰不及。遂入尺为覆，为内关外格，此阳
乘之脉也。故覆溢是其真脏之脉，人不病自死。大抵亦人迎气口之互见者也。云岐
子云∶阴阳易位，病名关格。胸膈上阳气常在，则热为主病。身半以下，阴气常在，
则寒为主病。寒反在胸中，舌上白胎，而水浆不下，故曰格，格则吐逆。热在丹田，
小便不通，故曰关，关则不得小便。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。柏子仁汤、人参散、
既济丸、槟榔益气汤、木通二陈汤、导气清利汤、加味麻仁丸、皂角散。孙尚药治
奉职赵令仪女，忽吐逆，大小便不通，烦乱，四肢渐冷，无脉，凡一日半，与大承
气汤一剂，至夜半，渐得大便通，脉渐和，翼日乃安。
关，指小便不通；格，指呕吐逆反，这是上下二焦同时患病的状况。所谓“格”，就是呕吐逆反。九窍、五脏的病，是阴气达到极点从地下上升，这属于行阳道，对应东方之气，如同金石发生变异，导致上部壅塞。当阴气极盛时，阳气之道无法运行，反而闭塞于上，所以使人呕吐逆反，这是地气不能上行所致。气机逆而下降，反而行于阴道，所以气机填塞而不能进入体内，此时气口脉比人迎脉大四倍，这是清气反而行于浊道，所以称为“格”。
所谓“关”，就是大小便不利（此处特指小便）。下窍、六腑的病，是阳气达到极点从天上降下，这属于行阴道，对应西方之气，如同膏粱厚味之物，导致下部泄利。当阳气极盛时，阴道无法运行，反而闭塞于下，所以小便不通，这是天气不得下行通畅所致。气机逆而上行，反而行于阳道，所以血脉凝滞而不通，此时人迎脉比气口脉大四倍，这是浊气反而行于清道，所以称为“关”。
有人问：关格的病因是怎样的？回答说：《内经》认为脏腑阴阳的病变，诊察表现于外的部位是在人迎和气口。说人迎脉大一倍，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。如果人迎和寸口脉都盛大，大四倍以上，就称为关格。关格的脉象羸弱，如果不能与天地精气相极应，就会死亡。注解说：格，是阳气盛极，所以格拒而使食物不能进入。关，是阴气盛极，所以关闭而使小便不通。
《灵枢》也曾三次提到这个问题，其中两次的内容，都与《内经》关于人迎、气口脉盛衰分属经脉的论述相同。但《灵枢》更进一步说：脉盛大的是足经，盛大且躁动的是手经。到了人迎脉大四倍，且大且数，名叫溢阳，溢阳即为外格。手太阴脉口大四倍，且大且数，名叫溢阴，溢阴即为内关。内关不通，死症不可治。人迎与太阴脉口都盛大四倍以上，名叫关格，关格的人寿命将尽。而如果人迎与脉口都盛大三倍以上，名叫阴阳俱溢，如果不及时疏通，则血脉闭塞，气无所行，流散淫溢于体内，五脏就会内伤。
凡针刺的原则，根据所分的程度，人迎一盛、三盛、五盛，泻其阳经，补其所合的阴经，比例是二泻一补；寸口脉也是如此，分泻其阴经，补其所合的阳经，比例是二补一泻，以上气调和为停止标准。另一种说法是邪气在腑，则阳脉不和，阳脉不和则气停留，气停留则阳气盛。阳气太盛则阴气不利，阴脉不利则血停留，血停留则阴气盛。阴气太盛则阳气不能荣养，所以叫关。阳气太盛则阴气不能荣养，所以叫格。阴阳都盛而不能相互荣养，所以叫关格。关格的人，活不到自然寿命期限就会死。
由此看来，前面论及人迎、寸口的，是因为人迎主外，气口主内，所以分三阴三阳，根据气的多少，定为一盛、二盛、三盛而言。像这种不提及人迎、寸口的，大概也有其深意。为什么呢？这是因为在讨论脉度时顺便提到的，以手足十二经周行上下者，是大经隧。然而一阴一阳经互为脏腑表里者，就有横向的支路，通达内外，脏腑阴阳之气与之相互荣养，所以在两手寸、关、尺六部作为诊法。浮脉则为腑病，沉脉则为脏病，在阴阳盛衰的表现上，难道完全从其分部来显现吗？所以不再专门提人迎、气口了。至于张仲景论及关格的话，就可以看出来了。他说：寸口脉浮而大，浮为虚，大为实，在尺部为关，在寸部为格，关则小便不通，格则呕吐逆反。又说：心脉洪大而长，这是心的本脉。如果脉上段微细头小，则汗出；下段微细本大，则为关格不通，小便不得排出。头部无汗的可以治，有汗的必死。又说：趺阳脉伏而涩，伏则呕吐逆反，水谷不化；涩则食物不能进入，名叫关格。
胃是水谷之海，营气居住的地方。营气是营卫的根源，营气的机制如果不活动，则卫气不布散，卫气不布散则脉伏，脉伏则谷不化而呕吐逆反；营气不行则脉涩，脉涩则食物不入。像这样都属于外格，未见内关的病，也通称为关格了。注家又认为涩脉是脾病，而且脾是阴脏。脾病则阴盛，阴盛应当是内关，怎么会是外格导致饮食不入呢？大概关格的名称含义，格，是抗拒捍卫于外，使进入的东西不能入内；关，是闭塞于内，使排出的东西不能泄出。这难道不是明白且详尽的吗？
后世胡乱地将小便不通称为格，大便不通称为关，泛指下部的阴阳二窍而言，对于阴阳的大法，不再穷究到底，这不仅限于此。又有将阴阳格绝的证候，通称为关格病的，是非错乱，令人叹息。
那种隔绝的证候，记载于《内经》中的，有说“隔”则是闭绝，上下不通，这是暴忧导致的病。注解说：忧愁则气闭塞不行，血脉断绝，所以大小便不得通。有说：病久则传化之行，上下不并，良医也难以救治。又有说：三阳结谓之隔。注解说：小肠膀胱热结也，小肠热结则血脉燥，膀胱热结则津液涸，所以隔塞而不便。又说：三阳积则九窍皆塞。又说：阳气蓄积致死，而阳气应当被阻隔，阻隔者应当用泻法，不紧急进行正确治疗，粗疏的医生就会败坏病情。
推究这几条，它们与关格究竟有什么关系呢？丹溪的书说：必须用吐法，提起横格之气，不一定非要吐出痰涎。又说：有痰证用二陈汤催吐，吐中便有降气之意。中气不运转的，在补气药中加入升降之品。这大概是窃取治疗小便的方法填在条文下，蹈袭世俗的弊端而不醒悟，可悲啊。
又考证王叔和的《脉经》，引用《难经》第八十一难的说法：有太过，有不及，有阴阳相乘，有覆有溢，有关有格。关之前者，是阳之动，脉应当见九分而浮，超过者，法曰太过，减少者，法曰不及。遂上至鱼际为溢，为外关内格，这是阴乘之脉。关以后者，是阴之动，脉应当见一寸而沉，超过者，法曰太过，减少者，法曰不及。遂入尺部为覆，为内关外格，这是阳乘之脉。所以覆、溢是其真脏之脉，人不生病也会自死。大体也是人迎、气口脉象的互见表现。
云岐子说：阴阳易位，病名关格。胸膈上阳气常在，则以热为主病。身半以下，阴气常在，则以寒为主病。寒反在胸中，舌上白苔，而水浆不下，所以叫格，格则呕吐逆反。热在丹田，小便不通，所以叫关，关则不得小便。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。方剂有柏子仁汤、人参散、既济丸、槟榔益气汤、木通二陈汤、导气清利汤、加味麻仁丸、皂角散。
孙尚药治疗奉职赵令仪的女儿，忽然呕吐逆反，大小便不通，烦乱，四肢逐渐变冷，无脉，经过一天半，给予大承气汤一剂，到半夜，逐渐大便通，脉逐渐平和，第二天才安定。
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.