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Chapter 18 states: There are three positions (cun, guan, chi) in pulse diagnosis, and each position corresponds to four meridians. The hands have the Taiyin (Lung/Large Intestine) and Yangming (Large Intestine/Stomach) meridians, while the feet have the Taiyang (Bladder/Kidney) and Shaoyin (Kidney/Heart) meridians, constituting the upper and lower sections. What is the meaning of this?

Hua Shou (Master Hua) says: The intent of posing this question in this chapter is to explain that humans have twelve primary meridians, divided into three positions, with four meridians associated with each position. Now, the Taiyin and Yangming meridians of the hand, and the Taiyang and Shaoyin meridians of the foot, are classified as the upper and lower sections. Why is this so? Generally speaking, "three positions" refers to dividing the pulse into upper, middle, and lower sections based on the Cun (inch), Guan (bar), and Chi (cubit) locations. "Four meridians" means that by comparing the Cun, Guan, and Chi positions pairwise, each section encompasses four meridians. The Hand Taiyin Lung Meridian and Hand Yangming Large Intestine Meridian, along with the Foot Taiyang Bladder Meridian and Foot Shaoyin Kidney Meridian, are referred to as the upper and lower sections because the Lung resides at the right Cun position, and the Kidney resides at the left Chi position. They support each other in a cyclical manner; the Lung is high and the Kidney is low, gazing at each other like mother and child. As the classics state: "The true Qi of the Zang organs is highest in the Lung and lowest in the Kidney," which refers to this principle.

However, the Hand Taiyin Lung Meridian and Hand Yangming Large Intestine Meridian belong to Metal, while the Foot Shaoyin Kidney Meridian and Foot Taiyang Bladder Meridian belong to Water. Metal generates Water; water flows downward and cannot ascend, hence they are assigned to the lower section. The Foot Jueyin Liver Meridian and Foot Shaoyang Gallbladder Meridian belong to Wood. Wood generates the Fire of the Hand Taiyang Small Intestine Meridian and Hand Shaoyin Heart Meridian. Fire flares upward and cannot descend, hence they are assigned to the upper section. The Hand Jueyin Pericardium Meridian and Hand Shaoyang Sanjiao (Triple Burner) Meridian belong to Ministerial Fire. Ministerial Fire generates the Earth of the Foot Taiyin Spleen Meridian and Foot Yangming Stomach Meridian. Earth governs the Central Palace (Spleen and Stomach), hence it is assigned to the middle section. These all illustrate the mutual generation and nourishment between the generating (mother) and generated (child) elements within the Five Phases (Wu Xing).

The Hand Taiyin Lung Meridian and Hand Yangming Large Intestine Meridian belong to Metal and are both palpated at the right Cun position. The Foot Shaoyin Kidney Meridian and Foot Taiyang Bladder Meridian belong to Water and are both palpated at the left Chi position. Metal generates Water, and water nature flows downward, so they belong to the lower section. The Foot Jueyin Liver Meridian and Foot Shaoyang Gallbladder Meridian belong to Wood and are both palpated at the left Guan position. The Hand Taiyang Small Intestine Meridian and Hand Shaoyin Heart Meridian belong to Fire and are both palpated at the left Cun position. Wood generates Fire, and fire nature flares upward, so they belong to the upper section. The Hand Jueyin Pericardium Meridian and Hand Shaoyang Sanjiao Meridian belong to Ministerial Fire and should be observed at the right Chi position. The Foot Taiyin Spleen Meridian and Foot Yangming Stomach Meridian belong to Earth and should be observed at the right Guan position. Fire generates Earth, and Earth occupies the central position, so it belongs to the middle section. Earth then generates Metal. This illustrates the principle of the Five Phases' mother-child cycle generating and nourishing the three positions and four meridians in their upper and lower distributions.

Regarding the three positions and nine examinations (positions) of the pulse, what does each primarily indicate?

Response: The "three positions" refer to Cun, Guan, and Chi. The "nine examinations" refer to the superficial (Fu), moderate (Zhong), and deep (Chen) palpation techniques. The upper section models Heaven and indicates diseases from the chest up to the head. The middle section models Humanity and indicates diseases from below the diaphragm to the umbilicus. The lower section models Earth and indicates diseases from below the umbilicus to the feet. One must examine carefully before applying acupuncture.

Within each of the three positions, there are superficial, moderate, and deep palpations, totaling nine examinations. Superficial palpation represents Yang, deep palpation represents Yin, and moderate palpation reflects Stomach Qi. It is said that above the diaphragm is the Upper Jiao (Upper Burner), below the diaphragm is the Middle Jiao (Middle Burner), and from the umbilicus down to the feet is the Lower Jiao (Lower Burner). Mr. Xie stated: This paragraph likely belonged to the answer in Chapter 16 but was misplaced due to bamboo slip disorder, resulting in the extra ten characters "Mai you san bu jiu hou, ge he zhu zhi?" (There are three positions and nine examinations of the pulse; what does each indicate?). Regarding "Shen er ci zhi" (Examine carefully and puncture), Master Yang interpreted it as examining the location of the disease to apply puncture; Mr. Ding suggested it meant following a sequence; Mr. Ji interpreted it as the meaning of observing the pulse during puncture. Each has its own logic, so we preserve them for reference.

Can chronic stagnation and long-standing accumulations (Ji Ju) in patients be known through pulse diagnosis?

Response: If there is accumulated Qi in the right hypochondrium, and the Lung pulse presents as a Knotted pulse (Jie Mai), the more pronounced the knotting, the greater the accumulation; if the knotting is slight, the Qi stagnation is slight. If the Lung pulse does not show knotting, yet there is accumulated Qi in the right hypochondrium, why is this?

Response: Although the Lung pulse does not appear knotted, the overall pulse on the right hand should present as Deep and Hidden (Chen Fu).

This type of long-standing accumulation can indeed be known through pulse diagnosis. Lung Metal descends to the right; the right hypochondrium is the domain of the Lung. If there is an accumulation in the right hypochondrium, the Lung pulse should be knotted. A Knotted pulse is characterized by a slow rhythm with occasional irregular pauses. Generally, the Knotted pulse is indicative of accumulation. The *Su Wen: Ping Ren Qi Xiang Lun* states: "A knotted and transverse pulse indicates accumulation." However, accumulations vary in severity; thus, a pronounced knotted pulse indicates severe accumulation, while a slight one indicates mild Qi stagnation. Even if the Lung pulse does not show knotting, the right-hand pulse should exhibit a Deep and Hidden quality. The Deep and Hidden pulse is also a sign of accumulation. "Right hand" here refers generally to the three positions (Cun, Guan, Chi) of the right hand, encompassing the Lung pulse. Furthermore, the Qi Kou (radial artery) on the right hand is used to diagnose interior conditions.

Do external stubborn diseases (Gu Ji) follow the same diagnostic principles as internal accumulations, or are they different?

Response: A Knotted pulse is one where the pulse occasionally stops during its arrival and departure without a fixed pattern. A Hidden (Fu) pulse is one that lies beneath the tendons. A Superficial (Fu) pulse is one that lies on the surface of the flesh. The principles for the left and right sides, exterior and interior, are all similar.

This follows the previous text, re-asking whether the diagnostic methods for external stubborn diseases and internal accumulations are the same or different. Stubborn diseases refer to any condition lingering in muscles, sinews, bones, and joints for a long time. Because they are not within the Zang-Fu organs, they are called "external." An irregular pause characterizes the Knotted pulse; if the pause were regular, it would be a Intermittent pulse (Dai Mai). The Knotted pulse arises because internal accumulations obstruct the pulse channels. The Hidden pulse is not visible with light pressure; only with heavy pressure, pushing the tendons to the bone, can the pulse form hidden among the bones be felt. Therefore, Knotted and Hidden pulses indicate interior disease; Knotted and Superficial pulses indicate exterior disease. If the Knotted pulse is on the right, the disease is on the right; if on the left, the disease is on the left. By inference, for internal or external accumulations and stubborn diseases, although the Knotted pulse may be similar, the distinction between Superficial and Hidden palpation differs. Hence, it is said that the principles are all similar.

If the pulse is Knotted and Hidden, but there is no internal accumulation; or if the pulse is Superficial and Knotted, but there is no external stubborn disease; if there is an accumulation but the pulse is not Knotted or Hidden; if there is a stubborn disease but the pulse is not Superficial or Knotted—this is called "pulse not corresponding to disease, disease not corresponding to pulse," which signifies a fatal condition.

Where there is a specific disease, there must be a corresponding pulse. Internal accumulations should manifest as Hidden and Knotted pulses; external stubborn diseases should manifest as Superficial and Knotted pulses. If Hidden or Superficial-Knotted pulses appear without corresponding symptoms, or if such symptoms appear without corresponding pulses, it is termed "pulse not corresponding to disease, disease not corresponding to pulse." When disease and pulse do not correspond, it means the vital Qi has dispersed and the blood vessels are no longer connected, hence it is considered fatal. In fact, any case where disease and pulse do not correspond is a sign of death, not just in cases of accumulation.