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Li Dongyuan stated: The ancients distinguished between external injuries (exogenous diseases) and internal injuries by comparing the Renying pulse and the Qikou pulse. When the Renying pulse is larger than the Qikou pulse, it indicates an external injury; when the Qikou pulse is larger than the Renying pulse, it indicates an internal injury. While this distinction is correct, their explanation is not exhaustive. External contraction of wind-cold belongs to excess syndromes caused by invading pathogenic factors, and the pathology must manifest on the left hand. The left hand governs the exterior (Biao), corresponding to the circulation of Yang qi for twenty-five cycles. Internal injuries due to improper diet, dietary irregularities, or overwork belong to deficiency syndromes, and the pathology must manifest on the right hand. The right hand governs the interior (Li), corresponding to the circulation of Yin qi for twenty-five cycles. Therefore, in cases of external cold contraction, only the left-hand Renying pulse appears floating and tight, feeling surging and large upon pressure. A tight pulse is more severe than a string-like pulse, representing the pulse of the Foot-Taiyang Bladder channel (Cold Water); feeling surging and large with strength reveals the pulse of the Hand-Shaoyin Heart channel (Fire). The combination of Ding (Yin Fire) and Ren (Yang Water) internally manifests as a surging-large pulse, which is the pulse pattern of Cold Damage (Shanghan). If external wind contraction occurs, the Renying pulse is slow and larger than the Qikou pulse by one, two, or three times. In cases of internal dietary injury, the right Cun position of the Qikou pulse is larger than the Renying pulse by one time; if the injury is severe, involving the Shaoyin channel, it is larger by two times, and involving the Taiyin channel, by three times. This constitutes the pulse pattern of internal dietary injury.

I believe that Li Dongyuan’s elucidation of the syndrome of internal injury has been of considerable merit. All his discussions that are precise and unchangeable are detailed below, while those that are slightly ambiguous are temporarily set aside. Regarding the differentiation of pulses, however, there is no room for failure to clarify the error of treating the left pulse as Renying governing the exterior and the right pulse as Qikou governing the interior; i.e., external contraction presents with a floating-tight left Renying pulse, while internal injury presents with a large right Qikou pulse. This is a shortcoming within his otherwise strong theory. Actually, the Renying pulse originally refers to the Stomach channel of Yangming, located on both sides of the laryngeal prominence, while the Qikou pulse refers to the Lung channel of Taiyin; both hands are commonly referred to as Qikou. It was Wang Shuhe of the Jin Dynasty who, for unknown reasons, abruptly claimed that the left pulse is Renying and the right is Qikou, with the left observing the exterior and the right observing the interior. Li Dongyuan followed this view and thus repeated it, which is a major error. Furthermore, the distinction between internal and external injuries lies in the difference between interior and exterior, which must not be confused. For instance, the Liver and Kidney are on the left; do they not have interior aspects? The Intestines and Stomach are on the right; are they not exterior aspects? Even Zhang Zhongjing’s discussion of Cold Damage distinguishes the exterior as floating-large and the interior as deep-thin. Tracing back before Zhang Zhongjing to Cang Gong, Bian Que, Xuanyuan, and Qibo, there was never mention of distinguishing interior/exterior by left/right. Only after Wang Shuhe did everyone follow his fallacy, leading to erroneous transmission.

Regardless of the exterior/interior relationships of the Six Channels, speaking from personal experience: if the pulse is tight and rapid, this indicates external cold contraction; however, there is no case where the left pulse is rapid while the right is not. Similarly, the claim that a large left pulse indicates wind evil and a large right pulse indicates dietary retention is particularly incorrect. In normal human constitution, nine or ten out of ten people have larger right pulses, while only one or two out of ten have larger left pulses. If yang pathogens are truly in the exterior, the large pulse would become even larger; how can one attribute it to food retention simply because the right pulse is naturally large? If food stagnates in the Zang organs, the strong pulse would become stronger; how can one attribute it to cold simply because the left pulse is naturally strong? One should not fail to realize that where the pulse is large and tight elsewhere, the smaller pulse there must also be tight; where the pulse is small and slow elsewhere, the large pulse here must also be slow. If one forms biased judgments based on partial strength, many will forget the fundamental nature of the pulse. Therefore, regarding size, pulse bodies differ and can be distinguished by left/right; but regarding speed, respiratory rates correspond and cannot be distinguished by left/right. Moreover, the theory of left-exterior/right-interior contradicts classic principles and does not reflect pathological signs; how can it be trusted?

Someone might ask: Then how should internal and external injuries be differentiated? I reply: All six pulses contain aspects of interior and exterior, and both left and right possess Yin and Yang. In external injuries, both hands present with tight and rapid pulses, but one must distinguish Yin and Yang syndromes based on strength or weakness. In internal injuries, both left and right pulses are slow and large, and one must differentiate deficiency from excess based on the presence or absence of "Shen" (Spirit/Vitality). However, one must examine the normal state of the left and right pulses to reference the duration of the etiology, thereby obtaining the true nature of the pulse and symptoms. Otherwise, interior/exterior may be misidentified, and attacking/supplementing methods may be reversed. Since Wang Shuhe to the present day, countless individuals have suffered harm from this; hence, it is necessary to correct these errors to assist Li Dongyuan’s work. This topic is discussed separately in *Lei Jing* (Classified Classic), Volume 10, Chapter 11, under Zang-Fu Manifestations, and should be cross-referenced.