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The Six Transformations refer to the six fundamental pathological mechanisms: Exterior (Biao), Interior (Li), Cold (Han), Heat (Re), Deficiency (Xu), and Excess (Shi). These are the key points in medicine. Understanding these six aspects allows one to comprehend all diseases as clearly as reading lines on one's palm. Regarding Exterior and Interior, wind, cold, summerheat, dampness, fire, and dryness invading from the exterior belong to Exterior patterns. Regarding Interior, emotional disturbances (Seven Emotions), overwork, sexual indiscretion, and dietary injuries damaging the interior belong to Interior patterns. Cold belongs to Yin. It can be Internal Cold or External Cold; Cold patterns are mostly Deficient. Heat belongs to Yang. It can be Internal Heat or External Heat; Heat patterns are mostly Excessive. Deficiency refers to insufficient Zheng Qi (Upright Qi); diseases originating from within often manifest as insufficiency. Excess refers to surplus pathogenic factors; diseases entering from outside often manifest as excess. The detailed explanations of these six are listed below.

Exterior patterns refer to diseases caused by pathogenic factors invading from the outside. Any abnormal qi such as wind, cold, summerheat, dampness, fire, and dryness falls into this category. The Classics state: "When clear wind arrives greatly, it indicates an excess of dryness. When wind-wood is affected by pathogens, Liver disease arises." "When heat qi arrives greatly, it indicates an excess of fire. When metal-dryness is affected by pathogens, Lung disease arises." "When cold qi arrives greatly, it indicates an excess of water. When fire-heat is affected by pathogens, Heart disease arises." "When damp qi arrives greatly, it indicates an excess of earth. When cold-water is affected by pathogens, Kidney disease arises." "When wind qi arrives greatly, it indicates an excess of wood. When earth-dampness is affected by pathogens, Spleen disease arises." It is also said: "If one is injured by cold in winter, one will surely suffer from warm diseases in spring. If one is injured by wind in spring, one will suffer from undigested food diarrhea in summer. If one is injured by summerheat in summer, one will surely suffer from coughing and malaria in autumn. If one is injured by dampness in autumn, one will surely suffer from coughing in winter." It is also said: "Wind coming from the Chonghou direction is called Empty Wind, which harms people and is the master of killing and harm." All these statements discuss external pathogenic factors. However, pathogenic factors have a distinction between Yin and Yang, and the sites they damage differ accordingly. Although there are six types of pathogens, their transformation归结s to Yin and Yang. Yang pathogens transform into Heat, and Heat damages Qi; Yin pathogens transform into Cold, and Cold damages the Form. Damaging Qi involves the nose connecting to the internal organs. Thus, when externally affected by summerheat and illness manifests internally, it is because Heat pathogens damaged Qi. Damaging Form affects the skin and hair superficially, and the meridians deeply. Thus, when externally affected by wind and cold and illness manifests as fever and body pain, it is because Cold pathogens damaged Form. The Classics state: "Cold causes the Cou Li (pores) to close and Qi movement to stagnate, so Qi becomes constrained. Heat causes the Cou Li to open, Ying and Wei Qi to circulate freely, leading to profuse sweating, so Qi leaks out." This is the distinction between the Yin and Yang of the Six Qi. However, among the Six Pathogens affecting the exterior, wind and cold are the most common. Wind is the leader of a hundred diseases, and cold is a lethal qi. Internally, humans have Zang-Fu organs; externally, they have Meridians. Whenever pathogenic factors lodge in the form, they first reside in the skin and hair; if not expelled, they enter the Sun Luo (branch collaterals); if not expelled, they enter the Luo Mai (collateral vessels); if not expelled, they enter the Jing Mai (main meridians), then internally connect to the Five Zang organs and scatter to the stomach and intestines. When both Yin and Yang are affected, the Five Zang organs are injured. This is the sequence of pathogens moving from exterior to interior. Since pathogens are at the Exterior, there must be Exterior symptoms. Once Exterior symptoms are present, one must not attack the Interior. If mistakenly attacked, not only is it ineffective, but it may cause Interior deficiency, allowing pathogens to sink deeper due to the void. Once Exterior patterns are clear, Interior patterns can be resolved accordingly. Therefore, distinguishing Exterior patterns requires prior examination.

First, human Zang-Fu organs are inside, and meridians are outside; thus, Zang-Fu are Interior, and meridians are Exterior. At the Exterior level, the hands and feet each have six meridians, totaling twelve Main Meridians. Dividing the twelve meridians by Yin and Yang, the six Yang meridians belong to Fu organs and represent the Exterior; the six Yin meridians belong to Zang organs and represent the Interior. Dividing by hand and foot, the foot meridians are long and distant, running from top to bottom and covering the four limbs, so diseases of the whole body can be examined by palpating them. Hand meridians are short and proximal, entering and exiting between the foot meridians. Therefore, when diagnosing Shanghan (Cold Damage) and exogenous diseases, only the foot meridians are discussed, not the hand meridians. Among the six foot meridians, the three Yang meridians are Exterior, and the three Yin meridians are Interior. Among the three Yang meridians, Taiyang is the Exterior of Yang because its meridian runs on the back, which is Yang. Yangming is the Interior of Yang because its meridian runs on the abdomen, which is Yin. Shaoyang is Half-Exterior Half-Interior because its meridian runs on the sides. After the three Yang meridians transmit fully, they gradually enter the three Yin meridians. Thus, to examine Exterior patterns, one should distinguish front, back, left, and right, focusing mainly on the three foot-Yang meridians. Among the three Yang meridians, the Taiyang meridian covers the shoulders and back, serving as the framework for the entire body externally and connecting to the Huang-Mo (diaphragm/membranes) of the five Zang and six Fu organs internally. It is the primary Qi of all Yang meridians, like a major intersection with roads extending in all directions. Therefore, when wind and cold injure humans, they usually start from the Taiyang meridian.

Second, the three foot-Yin meridians run from the feet up to the abdomen. Although they are between the muscles and skin, the three Yin meridians govern the Interior. Furthermore, whenever wind and cold invade from the Exterior, they do not enter the Yin divisions without passing through the Yang meridians. If they bypass the Yang meridians and directly enter the three Yin meridians, it is called Direct Transmission to Yin Meridians (Zhi Zhong), involving the Zang organs. Therefore, Yin meridians lack reliable Exterior symptoms.

Third, when Cold pathogens are at the Exterior, there is invariably fever without sweat, because the pathogens block the skin and hair.

Fourth, when Cold pathogens lodge in the meridians, there is invariably body pain, or stiffness and soreness, because the pathogens disrupt Ying Qi and impede blood vessel circulation.

Fifth, when Cold pathogens are at the Exterior causing headache, four meridians are involved. The Foot-Taiyang meridian flanks the vertex; the Foot-Yangming meridian ascends to Touwei; the Foot-Shaoyang meridian ascends to the temporal angles; the Foot-Jueyin meridian converges at the vertex. All can cause headaches. Therefore, only the Taiyin and Shaoyin meridians do not present with headaches.

Sixth, Cold pathogens at the Exterior often involve aversion to cold. Those injured by it inevitably dislike it, just as those injured by food dislike food, and those injured by cold dislike cold.

Seventh, when pathogens are at the Exterior, the pulse is invariably tight and rapid, because Ying Qi is disturbed by the pathogens.

Eighth, the Taiyang meridian originates from the inner canthus, ascends to the vertex, descends to the nape, and runs alongside the spine to the waist. Therefore, when pathogens are in the Taiyang meridian, there is invariably aversion to cold and fever, accompanied by headache and neck stiffness, back and spine rigidity, or knee soreness and pain.

Ninth, the Yangming meridian originates below the eyes, follows the face and nose, and runs through the chest and abdomen. Therefore, when pathogens are in the Yangming meridian, there is invariably fever with slight aversion to cold, accompanied by eye pain, nasal dryness, and insomnia.

Tenth, Shaoyang is the Half-Exterior Half-Interior meridian. Its meridian winds around the ears and passes from Jianjing down to the hypochondrium. Therefore, when pathogens are in the Shaoyang meridian, there is invariably fever accompanied by deafness, hypochondriac pain, bitter taste, vomiting, or alternating chills and fever.

The above are all Exterior patterns of the three Yang meridians. As long as Exterior patterns are present, one must not attack the Interior. One may use methods to release the Exterior, slightly resolve, warm-disperse, cool-disperse, or warm the Middle and support the Interior to achieve dispersion without dispersing, or tonify Yin to assist Yin to achieve dispersion like clouds evaporating and rain transforming. Alas! The meaning lies in mental comprehension and is hard to express fully. Only the wise can understand it intuitively.

Eleventh, regarding the pulse of Exterior patterns. Zhang Zhongjing said: "The Cun Kou pulse is floating and tight. Floating indicates wind, tight indicates cold. Wind injures Wei Qi, cold injures Ying Qi. When both Ying and Wei are diseased, causing bone and joint discomfort, one should induce sweating." The *Mai Jing* notes: "Wind is Yang, cold is Yin; Wei is Yang, Ying is Yin. Wind injures Yang, cold injures Yin, each injuring according to its kind. Thus, Wei becomes hot when affected by wind, Ying becomes painful when affected by cold. When both Ying and Wei are diseased, bone and joint discomfort results. One should induce sweating to resolve the Exterior and recover."

Twelfth, although a floating pulse inherently belongs to the Exterior, this is not absolute. In cases of severe initial exposure to cold pathogens, the Wei Qi is constrained, and the pulse cannot reach the surface, resulting in a deep and tight pulse. In such cases, one must combine the observation with Exterior symptoms like fever and body pain to distinguish it. Additionally, in cases of blood deficiency causing blood movement, the pulse is invariably large and floating. In cases of Yin deficiency and water depletion, the pulse is invariably large and floating. In cases of blazing internal fire, the pulse is invariably large and floating. In cases of Guan Ge (blockage) with Yin repelling Yang, the pulse is invariably large and floating. In all these cases, one cannot simply attribute a floating pulse to the Exterior. One must consider physical constitution, disease qi, and the presence or absence of external symptoms. If a non-Exterior pattern is mistaken for an Exterior pattern, death can occur in the blink of an eye.

Thirteenth, in exogenous cold pathogens, a large pulse indicates disease progression due to increasing pathogenic strength. However, the pulse must be large and tight to indicate progression. If the pulse was initially small and becomes large, or gradually becomes larger and slower, this indicates a shift from Yin to Yang, representing the gradual return of Stomach Qi and a sign of impending resolution.

Fourteenth, if Cold pathogens are unresolved and the pulse is tight but forceless, there is no hope of recovery. Why? Tightness indicates pathogenic factors; force indicates Yuan Qi (Original Qi). A tight but forceless pulse means excess pathogens and deficient Original Qi. With deficient Original Qi, how can pathogens be expelled? In such cases, one must ensure the gradual replenishment of Yuan Yang. Then the pulse will gradually become forceful, changing from small to large, from weak to solid, eventually becoming surging and slippery. As Yang Qi gradually reaches the surface, the Exterior will resolve. If the pulse becomes increasingly forceless while tightness and rapidity advance daily, it is a sign of critical danger and death.

Fifteenth, a disease must originate from the Exterior to be called an Exterior pattern. If it spreads from the Interior to the Exterior, it is not an Exterior pattern. The Classics state: "For diseases moving from Interior to Exterior, regulate the Interior. For diseases moving from Exterior to Interior, treat the Exterior." If a disease originates internally but manifests severely externally, treat the Interior first, then the Exterior. If a disease originates externally but manifests severely internally, treat the Exterior first, then regulate the Interior. This principle of priority between Interior and Exterior must be known.

Sixteenth, Shangfeng (Wind Injury) and Zhongfeng (Wind Stroke), despite both having "wind" in their names, should not both be treated as Exterior patterns. Shangfeng involves wind entering from the outside and can be treated with dispersing and warming methods; this is an Exterior pattern. Zhongfeng, although resembling wind symptoms, is actually caused by internal injury. There is no external pathogen, so it should not be treated as an Exterior pattern. See the specific section for treatment methods.

Seventeenth, fever-like symptoms are essentially Fire patterns, but one must distinguish between Exterior and Interior. When pathogens are at the Exterior causing fever, it is Exterior Heat without Interior Heat, caused by Cold pathogens; treatment should focus on dissipation. When pathogens are at the Interior causing fever, Interior Heat is severe first and then affects the Exterior; this is a Fire pattern, and treatment should focus on cooling. Both internal and external cases can be discussed under Exogenous Heat. However, bone-steaming night fever due to Yin deficiency and water depletion is Deficient Heat. It should not be treated as Exogenous Heat; instead, strengthening Water and nourishing Yin is required.

Eighteenth, Dampness and Dryness, though categories of external pathogens, each have Yin and Yang aspects. Dampness following Yin is Cold-Dampness; dampness following Yang is Damp-Heat. Dryness following Yang is due to Fire; dryness following Yin arises from Cold. Heat damages Yin and connects to the Zang organs. Cold damages Yang and connects to the meridians. This is why Dampness and Dryness both have Exterior and Interior distinctions that must be clarified for treatment.

Nineteenth, distinguishing Dampness patterns requires differentiating Exterior and Interior. The Classics state: "Affected by dampness, the head feels wrapped." Also: "Those injured by dampness, the lower part is affected first." Walking in wind and rain or working hard until clothes are soaked with sweat represents dampness entering from the outside. Indulging in alcohol, raw, and cold foods leading to diarrhea, jaundice, and swelling represents dampness arising from the inside. For dampness located upper and external, mild diaphoresis is suitable. For dampness located lower and internal, promoting urination is suitable. Damp-Heat should be cleared and drained; Cold-Dampness should be treated by tonifying the Spleen and warming the Kidneys.

Twentieth, distinguishing Dryness patterns also involves Exterior and Interior. The Classics state: "Clear qi arrives greatly, indicating an excess of dryness. Wind-wood is affected, and Liver disease arises." This belongs to Zhongfeng. Generally, excessive dryness leads to Yin deficiency, and Yin deficiency leads to blood shortage, causing traction, stiffness, wasting of skin and pores, or dryness and constipation of Zang-Fu organs. This is Dryness transforming via Yang, with insufficient Ying Qi and internal damage. Treatment should focus on nourishing Ying and tonifying Yin. If Autumn energy is excessive, Metal qi prevails, and wind follows, the Lung is affected first. This belongs to Shangfeng. Cold and wind bind externally, affecting the skin and hair, causing fever without sweat, coughing and wheezing, nasal congestion and hoarseness, or dry throat. This is Dryness generated via Yin, with Wei Qi affected and external damage. Treatment should focus on light, ascending, warming, and dispersing agents to warm the Lung and dispel cold.