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Cheng Wuji: "Zhen" (trembling/shivering) refers to the body shaking; "Zhan" (rigid shivering) refers to violent trembling; "Li" (inner fear/trepidation) refers to inner mental dread. Zhen is mild, while Zhan is severe; Zhen manifests externally, whereas Li manifests internally. Zhen is attributed to deficiency and cold; because deficiency is insufficient to cause intense struggle, it only results in bodily shaking. Zhan occurs when righteous Qi (Zheng Qi) struggles with pathogenic factors (Xie Qi); the intensity of the struggle causes thigh tremors and body rigidity. Although Zhan is heavier than Zhen, Li is heavier than Zhan. Zhan indicates that righteous Qi prevails, while Li indicates that pathogenic factors prevail; both are manifestations of the struggle between righteous Qi and pathogens.

In Taiyang disease (Taiyang syndrome) caused by Cold damage (Shanghan), if purgation or emesis has been performed, symptoms such as fullness and rebellious Qi sensation below the heart (epigastric distension with upward rushing of Qi), Qi rushing up to the chest, dizziness upon rising, and a deep, tight pulse may occur. If sweating therapy is applied at this stage, it will disturb the meridians, causing the whole body to tremble and sway. The formula Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractodes Macrocephala, and Licorice Decoction) should be administered. (Cheng Wuji's commentary: After emesis or purgation, the interior is deficient, leading to rebellious Qi and epigastric fullness/rushing Qi; exterior deficiency and Yang insufficiency lead to dizziness upon rising. A floating, tight pulse indicates exterior pathogens requiring sweating; a deep, tight pulse indicates interior pathogens where sweating is contraindicated. Incorrect sweating disturbs the meridians and damages Yang. Exterior Yang deficiency fails to govern the vessels, causing body tremors. This formula harmonizes the meridians and benefits Yang.)

Formula for Fuling Guizhi Baizhu Gancao Tang (Poria, Cinnamon Twig, Atractodes Macrocephala, and Licorice Decoction):
Guizhi (Cinnamomi Ramulus, peeled, 3 liang), Fuling (Poria, 4 liang), Baizhu (Atractodis Macrocephalae Rhizoma), Gancao (Glycyrrhizae Radix et Rhizoma, each 2 liang, honey-fried). These four ingredients are boiled in 6 sheng of water to obtain 3 sheng. Strain and divide into three warm doses. (Commentary: For Yang insufficiency, sweet herbs like Fuling and Baizhu generate fluids and benefit Yang; for interior rebellious Qi, acrid herbs like Guizhi and Gancao promote Yang and dissipate Qi.)

In Taiyang disease, after sweating therapy, if the condition does not resolve despite sweating, and the patient still has fever, palpitations, dizziness, twitching muscles, and feels as though they are about to fall to the ground due to severe trembling, the formula Zhenwu Tang (True Warrior Decoction) should be administered. (See formula under "Diarrhea".)

Sun Yikui: Daoist Zhou Dezhen from Taiyi Palace suffered from Shanghan. Excessive sweating led to palpitations, dizziness, and violent trembling as if falling. Physicians suggested further sweating, treating it as wind-stroke, or using cold herbs to clear heat, but none were effective. I was summoned and said: "This is a Taiyang meridian disease. Sweating should have resolved it, but it did not because, although the Taiyang meridian desired to resolve via sweating, Kidney Qi was insufficient to produce sweat, resulting in palpitations, dizziness, and body turning. I prescribed Zhenwu Tang. After three doses, slight sweating occurred naturally, and the disease resolved. Zhenwu Tang contains Fuzi (Aconiti Lateralis Radix Praeparata) and Baizhu to harmonize Kidney Qi; once Kidney Qi moves, sweat can be produced. If one only treats the Taiyang meridian, it will only dry up the blood. Zhang Zhongjing stated: 'If the Chi pulse is deficient and Ying Qi (Nutritive Qi) is insufficient, sweating is contraindicated.' Thus, it is clear that weak Kidney Qi makes sweating difficult. Xu Xueshi said: 'A villager’s son, aged thirty, initially had slight sweating, weak pulse, and aversion to wind. The physician gave him Mahuang (Ephedrae Herba) to induce sweating. Sweating continued excessively, accompanied by fever, frequent palpitations, insomnia, delirium, inability to recognize people, twitching muscles, and violent trembling. The physician then administered heart-calming herbs. I said: This is an error caused by forced sweating. Zhang Zhongjing stated: 'With a faint pulse, sweating, and aversion to wind, Qinglong Tang (Green Dragon Decoction) is contraindicated. Administering it leads to twitching muscles, which is a adverse reaction. Only Zhenwu Tang can save this case.' He took three doses of this, supplemented with Qingxin Zhuye Tang (Clear Heart Bamboo Leaf Decoction), and recovered in a few days. (The formula for Qingxin Zhuye Tang could not be verified)."

After purgation followed by re-sweating, chills and trembling inevitably occur, with a fine pulse. This is because both the interior and exterior are deficient. Patients who have lost blood (Wangxue Jia) must not undergo sweating therapy; doing so will result in chills and trembling. In Taiyang disease, if the back is scorched with hot iron, causing excessive sweating, and the fire-heat enters the Stomach causing delirium, if after ten-plus days the patient experiences trembling and spontaneous diarrhea, this indicates the disease is resolving. (See "Delirium".)

A deep, tight pulse that feels hollow (Kou) upon pressure indicates that trembling followed by sweating will resolve the disease. A Kou pulse signifies deficiency, hence trembling; a floating pulse indicates exterior pathogens, so sweating will resolve it. (See discussion in Volume 1.) In Taiyang disease, when pulses at Yin and Yang positions are equally stopped/silent, trembling and sweating will resolve the disease. (See discussion on "Fever".) In all Chaihu syndromes (Bupleurum syndromes), if purgation fails to resolve the condition, administering Chaihu Tang again will cause vigorous trembling (Zhengzheng er Zhen) followed by fever, sweating, and resolution. (See discussion on "Alternating Chills and Fever".) A floating and slow pulse with a red-hot face and trembling/fear indicates resolution via sweating. If there is contrary fever, a slow pulse prevents sweating, and the body will itch. (See discussion on "Red Face".) All conditions caused by Cold invasion result in Jue Ni (cold extremities), Yu Mao (depression/dizziness), numbness, oral stiffness/inability to speak, and trembling. Pathogens invading the Yin aspect cause internal trembling. This is because exterior Qi is slightly deficient and interior Qi is unguarded, allowing pathogens to enter the Yin.

Han Zhihe: For trembling after sweating and purgation, use Jiuni Tang (Rescue Adverse Reaction Decoction); if symptoms decrease slightly, administer Moutang (Mutton Soup) again to resolve trembling. If interior Yin is abundant, Righteous Qi is greatly deficient, with inner fear, jaw quivering, but no body trembling, leading to Cold reversal, moxibustion should be used, or Dajianzhong Tang (Great Construct the Middle Decoction) administered. Zhang Zhongjing treated Shi Jue (Corpse-like Coma) with trembling by needling Qimen (LR14) and Jueque (CV14).

Wu Kun: Generally, trembling is due to deficiency of both Qi and Blood, where Qi fails to nourish sinews and bones, causing shaking and loss of motor control. Greatly tonifying Qi and Blood is required. I once used Renshen Yangrong Tang (Ginseng Nourishing Qi and Blood Decoction) with success. Another patient with body shaking and insomnia recovered using Shimei Wendan Tang (Ten-Ingredient Gallbladder-Warming Decoction) with doubled Renshen. The *Neijing* states: "Cold invading the body causes hair to stand erect, jaw quivering, and trembling without sweating." This belongs to exterior Cold causing trembling. The classics state: Disease resolves via trembling and sweating when the pulse is floating and tight but feels hollow upon pressure, indicating root deficiency necessitating trembling before sweating. It also states: When pulses at Yin and Yang positions are equal, trembling and sweating precede resolution. If the pulse is floating and rapid but not hollow, and the patient is not inherently deficient, sweating resolves the disease without trembling. If there is no trembling but inner fear (Li), this indicates pathogens invading the Yin, causing internal trembling. Whenever Righteous Qi is weak and Cold pathogens are inside, trembling occurs. Students should investigate this carefully.

Jiawei Renshen Yangrong Tang (Modified Ginseng Nourishing Qi and Blood Decoction): Treats excessive sweating leading to Qi and Blood deficiency, with twitching muscles or body trembling.
Renshen (Panacis Ginseng Radix, 2.5 qian), Fuling (Poria), Gancao (Glycyrrhizae Radix et Rhizoma), Chuanxiong (Ligustici Chuanxiong Rhizoma, each 1 qian), Baizhu (Atractodis Macrocephalae Rhizoma), Maidong (Ophiopogonis Radix, heart removed), Danggui (Angelicae Sinensis Radix, body part, each 1.5 qian), Wuweizi (Schisandrae Fructus, 15 grains), Rougui (Cinnamomi Cortex, 1 qian, halve if heat is present), Shengdihuang (Rehmanniae Radix, 1.5 qian; use this if heat is present, use Shudihuang if no sweating), Huangqi (Astragali Membranacei Radix, 2.5 qian, use 2 qian if spontaneous sweating), Shengjiang (Zingiberis Rhizoma Recens, 3 slices), Zaozi (Jujubae Fructus, 2 pieces, split). Boil in 2 zhong of water to 1 zhong, strain, and take warm. If Yin deficiency with ministerial fire movement, add Zhimu (Anemarrhenae Rhizoma) and Huangbai (Phellodendri Cortex) each 1 qian, wine-fried. If Yang deficiency with lower Cold and faint pulse, add Shufuzi (Aconiti Lateralis Radix Praeparata) 1 qian and double Rougui. For insomnia, add Yuanzhi (Polygalae Radix) and Suanzaoren (Ziziphi Spinosae Semen) each 1 qian.

Jiawei Wendan Tang (Modified Gallbladder-Warming Decoction): Treats deficiency-heat irritability, body trembling, and insomnia.
Renshen (Panacis Ginseng Radix, 2.5 qian), Juhong (Citri Reticulatae Pericarpium Rubrum), Fuling (Poria), Huanglian (Coptidis Rhizoma, wine-fried), Chaihu (Bupleuri Radix), Danggui (Angelicae Sinensis Radix, body part), Chuanxiong (Ligustici Chuanxiong Rhizoma), Baishao (Paeoniae Radix Alba), Shengdihuang (Rehmanniae Radix), Suanzaoren (Ziziphi Spinosae Semen, each 1 qian), Banxia (Pinelliae Rhizoma, 0.7 qian), Gancao (Glycyrrhizae Radix et Rhizoma, 0.5 qian), Zhuru (Bambusae Caulis in Taenia, one ball), Shengjiang (Zingiberis Rhizoma Recens, 3 slices). Decoct and take as described above.