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All died. (*Ji Yin Gang Mu*)

When the pulse at the cun, guan, and chi positions are all vigorous, it is called twin pregnancy (Shuang Qu). If the Shaoyin pulse is slightly tight, the blood will coagulate and become turbid, leading to insufficient nourishment from the menses, causing one fetus to wither and die while the other survives. If the dead fetus is not expelled, it will harm the mother and endanger the living fetus. The Shenzao San (Divine Creation Powder) from *Qian Jin Fang* (Essential Prescriptions Worth a Thousand Gold) is specifically used to treat cases of twins where one dies and one lives. It uses crab claws (Xie Zhua) to expel the dead fetus, Donkey-hide gelatin (Ejiao, Asini Corii Colla) to secure the living fetus, and Licorice root (Gancao, Glycyrrhizae Radix) to harmonize the properties of the herbs. The intention behind this prescription is profound. (*Feng Shi Jin Nang*)

Selected Case
The wife of Gu Jiye bled vaginally at five months of gestation. Physicians used Ginseng root (Renshen, Panacis Ginseng Radix) and Donkey-hide gelatin (Ejiao, Asini Corii Colla) to stabilize the fetus, resulting in generalized edema and abdominal distension. Counterflowing blood rushed upward, accumulating between the epiglottis and the chest/diaphragm. Food intake caused pain upon contact, followed immediately by vomiting. A subsequent physician diagnosed this as fetal qi pressing upward, spleen deficiency causing swelling, and formation of Ge Ye (Dysphagia/Esophageal Obstruction). They used the tonifying effects of Ginseng root (Renshen, Panacis Ginseng Radix) and the astringent properties of Schisandra fruit (Wuweizi, Schisandrae Chinensis Fructus). By the eighth month, her breathing was nearly exhausted. Pulse diagnosis revealed a faint and choppy chi pulse that was difficult to palpate, and an excessively flooding lung pulse. Her wheezing sounded like sawing wood, and her arms were cyanotic, swollen, and shiny. I said: "I see this condition clearly, like looking into a mirror. There is no need to state it explicitly to avoid causing panic. We should temporarily use effective herbs to unblock the lower obstruction and upper congestion." Jiye insisted on knowing the disease name. I said: "The upper congestion is indicated by the flooding lung pulse combined with the blockage at the epiglottis, suggesting lung abscess (Fei Yong); the lower obstruction is indicated by the faint and choppy chi pulse combined with the cyanotic and swollen flesh, indicating the fetus has been dead for a long time. The 'effective herbs' refer to Xie Bai San (White-Draining Powder) added with bitter herbs like Scutellaria root (Huangqin, Scutellariae Radix) and Platycodon root (Jiegeng, Platycodi Radix) to open the blockage, avoiding harsh drugs like Mirabilite (Xiaoshi, Natrii Sulfas) or Rhubarb (Dahuang, Rheomi Radix et Rhizoma). After one large dose, she experienced immediate abdominal labor pains. Jiye asked: 'Is she giving birth?' I said: 'The lung qi has opened and descended. After hours of closure and rejection, the foul matter can now be expelled. This is not delivery.' After another dose, the body swelling subsided slightly, and the upward rushing qi calmed. She discharged several dou of white, pus-like discharge containing the putrid fetus. For over ten days, she continued to discharge white turbidity without any blood. This indicates the fetus had been rotting in the abdomen for nearly 100 days; the blood nourishing the fetus had turned to pus along with the fetus. The patient's chest felt open, she could eat porridge, and her spirit was clear. However, although the putrid fetus was gone, the foul qi still filled her body, and the generalized cyanotic swelling remained; although the chest/pharynx was relaxed, the lung qi congestion causing chills, fever, and coughing persisted. I focused on clearing the lung, and she was completely cured. (Yu Jiayan)

Xu Yuqing treated the wife of Shao Hanzhen, who was seventeen months pregnant and had not delivered. He did not rely solely on pulse diagnosis but asked about her condition, confirming it was pregnancy, not illness. She reported that since the fifth month, the fetus had not moved, which surprised him internally. He prescribed a single herb, Salvia miltiorrhiza root (Danshen, Salviae Miltiorrhizae Radix), seven qian daily. After more than twenty days, the fetus was delivered, already dead and dried up. The death of the fetus likely occurred when movement stopped at five months. After thirteen months, the fetus did not rot in the uterus. Just as a fruit hanging on a tree rots if decayed, there are exceptions where it does not rot, allowing us to infer the principle of a dried fetus. (*Zhang Shi Yi Tong*)

Ghost Fetus (Gui Tai)
There is a concept of "ghost fetus" in women. Could it be that formless ghostly qi truly invades the uterus and takes shape? This is merely due to the woman's constitution, or perhaps obsessive thoughts accumulate, causing blood to knot with qi and not disperse; or because the Chong and Ren meridians are stagnant and reversed, causing the pulse channels to be congested and blocked. These are internal diseases, definitely not external pathogens, but rather belong to blood stasis or qi masses. They should be treated using methods for treating masses. (Zhang Jingyue)

Someone asked: Why do women conceive "ghost fetuses"? The answer is: Thoughts during the day become dreams at night. Those with licentious natures and deficiency often experience constant stirring of the ministerial fire in the liver and kidney. Thus, patients with consumption and weakness often dream of intercourse with ghosts. The so-called "ghost fetus" is a pseudo-fetus. It is not formed by actual intercourse with deities. Ancient texts say: Endless thoughts and unfulfilled desires lead to leukorrhea (Bai Yin/Bai Zhuo) flowing into the uterus, knotting into a ghost fetus. It is actually the woman's own blood and essence condensing into a mass, causing abdominal distension, resembling pregnancy. (Yu Tianmin)

Selected Case
A young woman named Yang visited a temple at dusk, saw a figure in yellow robes, and felt her heart move. That night she dreamed of intercourse, and her abdomen swelled as if pregnant. Boren diagnosed it as a "ghost fetus." After she explained the cause, he gave her blood-breaking and abortifacient herbs. She passed about two sheng of material resembling tadpoles or fish eyes, and then recovered safely. Was this not intercourse with a deity? The response was: The event happened, but the logic does not exist. How could a wooden or earthen form have intercourse with humans and produce semen to form a fetus? This was not the deity influencing the woman, but the woman's mind being influenced by the deity. (*Feng Shi Jin Nang*)

Conception and Sex Determination
When man and woman unite, their emotions flow smoothly. If yin blood arrives first and yang essence follows later, the blood opens to wrap the essence. The essence enters to form bone, resulting in a male. If yang essence enters first and yin blood follows, the essence opens to wrap the blood. The blood enters to form the root, resulting in a female. (*Chu Shi Yi Shu*)

The virtue of Heaven and the qi of Earth achieve perfect harmony, flowing and merging as one. Movement driven by qi to the left belongs to Yang; supported by Yang, it becomes male. Movement driven by qi to the right belongs to Yin; supported by Yin, it becomes female. (*Sheng Ji Jing*)

One or two days after menstruation ends, the Blood Sea is just cleared. Essence surpasses blood; conception results in a male. Four or five days later, blood vessels are vigorous; essence cannot surpass blood; conception results in a female. Six or seven days later, even if intercourse occurs, conception will not happen. (Li Dongyuan)

The *I Ching* states: The Way of Qian creates males, the Way of Kun creates females. Qian and Kun represent the nature of Yin and Yang. Left and Right represent the pathways of Yin and Yang. Male and Female represent the manifestations of Yin and Yang. Father's essence and Mother's blood meet through mutual influence. The emission of essence is the action of Yang. Blood captures essence; essence forms bone. This is how all things begin from Qianyuan (Primordial Yang). The movement of blood; essence cannot capture blood to form the womb. This is how all things are nurtured from Kunyuan (Primordial Yin). When Yin and Yang intertwine, the embryo begins to congeal. The place where the fetus resides is called the Uterus (Zi Gong). It has a cord below and bifurcates above, one reaching the left and one to the right. If essence surpasses blood, Yang dominates, receiving qi in the left uterus, forming a male. If essence does not surpass blood, Yin dominates, receiving qi in the right uterus, forming a female. Only after pregnancy is established does the placenta differentiate. (Zhu Danxi)

If we believe Chu Shi, then men emitting essence first bear sons, and those emitting last bear daughters. If we believe Li Dongyuan, then intercourse immediately after menstruation ends bears daughters, and intercourse after menstruation has ended for some time bears sons. There are also cases where intercourse before the fourth or fifth day results in no pregnancy, while intercourse after the eighth or ninth day results in pregnancy. Yu Ziben also stated: Weak Yang cannot penetrate Yin, and weak Yin cannot capture Yang. Believing this, we see that frail husbands and timid wives often conceive repeatedly, while those with robust blood/qi and abundant energy often suffer infertility. Danxi focused primarily on the woman's menstrual cycle. However, in wealthy households, many serve outside families; surely some have regular cycles? Generally, parents having children is like Heaven and Earth producing life. The *I Ching* says: "The Way of Kun is to follow and carry out the movements of Heaven according to time." Knowing that Earth produces life by following Heaven, we know that mothers bearing children also follow fathers. Knowing that mothers follow fathers, is seed-conception primarily dependent on the woman or the man? If dependent on the man, age, strength, health, or illness do not matter; whether essence emits easily or with difficulty, the key is that all pulses arrive simultaneously at the time of intercourse. If sex determination is not constrained by the order of essence/blood, days since menstruation, time of night, or parental strength, but only by which essence/blood and all pulses arrive with greater force: then if essence/pulses prevail over blood, it is male; if blood/pulses prevail over essence, it is female. (Cheng Mingqian)

The *Classic* states: Left and Right are the pathways of Yin and Yang. Male and Female are the manifestations of Yin and Yang. Thus, when Yin and Yang harmonize, all things are born; when husband and wife unite, male and female forms appear. It is evident that the birth of males and females is fundamentally based on the principles of Yin and Yang. Chu Cheng distinguished sexes by the order of essence and blood; Li Dongyuan by odd/even days; Mingqian by the simultaneous arrival of all pulses. All these theories are imprecise. Danxi criticized Chu and Li's theories as incomplete, citing the *I Ching*'s Qianyuan initiating creation and Kunyuan nurturing life. Lou Quanshan praised this as extremely subtle, revealing what predecessors had not. Regarding the theory that the uterus has left and right branches distinguishing sexes: The uterus is the Gate of Life (Ming Men). In women, the uterus holds the fetus, shaped like a closed bowl. How can it have left/right branches? This implies two uteri, which is baseless speculation. *Sheng Ji Jing* distinguishes sexes by left/right Yin/Yang without dividing the uterus. Moreover, during intercourse, both parties have essence; where is the blood? Chu, Li, and Danxi mixed essence and blood, rarely noting that in conception, the woman provides blood. Predecessors' discussions contain many errors, so I venture to clarify. (Xiao Shenzhai)

Pulse Signs
If the Hand-Shaoyin pulse beats vigorously in a woman, she is pregnant. ○ If the Yin pulse beats forcefully and differs from the Yang pulse, it is called pregnancy. ○ How do we know pregnancy is near term? The body shows signs of illness, but the pulse lacks pathogenic characteristics. (*Su Wen*)

The *Nei Jing* states that a vigorous Hand-Shaoyin pulse indicates pregnancy, and a strong Yin pulse differing from Yang indicates pregnancy. "Vigorous" and "Strong" both indicate forcefulness. However, *Jin Gui Yao Lue* (Essential Prescriptions of the Golden Cabinet) describes pregnancy as having a small and weak Yin pulse, thirst, inability to eat, and no chills/fever. Why are these contradictory? The *Nei Jing* refers to: 1) Blood accumulation and Qi abundance in the Kidney pulse (Hand-Shaoyin), causing pulsation; 2) Yin gaining fetal Qi and becoming strong, causing the Yin pulse to beat against the finger, while the Yang pulse differs. These are verified at three months. The *Jin Gui* description refers to: Lower Jiao Qi and Blood being temporarily depleted by the fetus, causing a small/weak pulse. This is verified around two months; later, it changes. Hence, the text mentions symptoms appearing around sixty days. Thus, the two books seem opposite but are actually consistent. Combining this with *Qian Jin* (Thousand Gold Formulas) stating early chi pulse is minute/small with five breaths per respiration, verified at three months, yields a comprehensive understanding. (*Wu Yi Hui Jiang*)

Pregnancy pulses are rapid, similar to exhaustion (Sun) pulses. However, exhaustion pulses are often wiry and choppy; pregnancy pulses are smooth and rapid. One must distinguish pathogenic Qi from Stomach Qi in subtle details. ○ In pregnancy, blood gathers and Qi accumulates, making the uterus full; thus, the pulse is smooth and rapid, exceeding normal levels. This is natural. However, in middle-aged conception or women with weak blood/qi, small and non-rapid pulses may occur. Yet, within the weakness, there is always a hidden smooth/sliding quality, which is the meaning of "Yin beating strongly while Yang differs." ○ Methods for determining sex are contradictory throughout history. I determine them using Kan and Li trigrams. Kan represents Heaven-One; Kan is full inside, representing Yang within. Li represents Earth-Two; Li is empty inside, representing Yin within. Obtaining Kan imagery indicates male; Li imagery indicates female. Thus, male pulses are often deep and solid (image of fullness); female pulses are often floating and deficient (image of emptiness). Regardless of age, strength, or pulse position, observing the imagery aligns perfectly, especially at the chi positions. ○ Dividing Yin/Yang by Left/Right: Left is Yang, Right is Yin. By Cun/Chi: Cun is Yang, Chi is Yin. By pulse body: Forceful/deep/solid is Yang; Weak/floating/choppy is Yin. Predominantly Yang/Solid indicates male; Predominantly Yin/Deficient indicates female. This is the definitive conclusion. (Zhang Jingyue)

If a woman's menses stop for two or three months, and the pulse is slightly smooth and rapid without interruption, though the body feels ill, the lack of pathogenic pulse confirms pregnancy. To determine sex: Ancients said larger left pulse is male, larger right is female. But constitutions vary. The most crucial rule is: Smooth and solid Cun pulse indicates male; smooth and solid Chi pulse indicates female. Both Cun smooth/solid = twin boys; Both Chi smooth/solid = twin girls; Right Chi and Left Cun smooth/solid = one boy, one girl. This is frequently verified. (*Zhang Shi Yi Tong*)

Selected Case
A woman over forty, with a robust appearance, had irregular menses. Both hands' pulses were imperceptible, except for a faint movement at the Right Guan position. Fine palpation at Jingqu (LU7) and Lieque (LU7) points also yielded no pulse. I was puzzled. Asking her husband, he said: "During a previous pregnancy, doctors also found no pulse. She took Ba Wu Tang (Eight Substances Decoction) and fortunately delivered a son." I said: "This is due to congenital constitution, nothing strange. Worldly affairs are infinitely variable and hard to predict by standard logic. *Mai Jing* (Pulse Classic) only describes norms. Here, no pulse in both hands does not harm life or the fetus. Can *Mai Jing* explain this? This is theoretically absent but factually present." (Wang Shishan)