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Cheng Wuji: "Zhen" (trembling/shivering) refers to shaking; "Zhan" (shuddering) refers to violent trembling; "Li" (internal shuddering) refers to mental or visceral shivering. Zhen is mild, while Zhan is severe; Zhan manifests externally, whereas Li manifests internally. Zhen is attributed to deficiency and cold; due to deficiency, there is insufficient energy for intense struggle, so it remains merely as shaking. Zhan occurs when righteous Qi (Zheng Qi) struggles against pathogenic factors (Xie Qi); this struggle causes thigh tremors and shuddering. 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 righteousness and pathogens.

In Taiyang Cold Damage disease, if purgation or emesis has been performed, leading to a sensation of fullness and rebellious Qi rising in the epigastrium (Xin Xia Ni Man), with Qi rushing upward to the chest, dizziness upon standing, and a deep, tight pulse. If sweating therapy is applied at this stage, it will disturb the meridians, causing the body to tremble and sway. The formula Fu Ling Gui Zhi Bai Zhu Gan Cao Tang (Poria, Cinnamon Twig, Atractodes Rhizome, and Licorice Decoction) should be administered. (Cheng Wuji's commentary: After emesis or purgation, the interior is deficient, causing Qi rebellion, hence the epigastric fullness and upward rushing Qi. Exterior deficiency and Yang insufficiency lead to dizziness upon standing. A floating, tight pulse indicates exterior pathogens requiring sweating; a deep, tight pulse indicates interior pathogens where sweating is contraindicated. Incorrect sweating disturbs the exterior meridians and damages Yang. Yang deficiency fails to govern the vessels, resulting in bodily tremors. This decoction harmonizes the meridians and benefits Yang.)

Formula for Fu Ling Gui Zhi Bai Zhu Gan Cao Tang (Poria, Cinnamon Twig, Atractodes Rhizome, and Licorice Decoction):
Gui Zhi (Cinnamomi Ramulus, peeled, 3 liang), Fu Ling (Poria, 4 liang), Bai Zhu (Atractodis Rhizoma, 2 liang), Gan Cao (Glycyrrhizae Radix et Rhizoma, honey-fried, 2 liang). 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 Poria and Atractodes generate fluids and benefit Yang. For interior Qi rebellion, pungent herbs like Cinnamon Twig and Licorice circulate Yang and dissipate Qi.)

In Taiyang disease, after sweating therapy, if the condition persists despite perspiration, with continued fever, palpitations, dizziness, muscle twitching, and severe trembling as if falling to the ground, Zhen Wu Tang (True Warrior Decoction) should be administered. (See formula under "Diarrhea".)

Sun Yikui: Daoist Zhou Dezhen from Taiyi Palace suffered from Cold Damage. Excessive sweating led to palpitations, dizziness, and violent trembling as if falling. Physicians proposed various treatments: further sweating, treating as wind syndrome, or using cold medicines to clear heat, but none were effective.
Upon consultation, Sun stated: "This is a Taiyang meridian disorder. Sweating should have resolved it, but it did not because, although the Taiyang meridian desired to resolve through sweating, Kidney Qi was insufficient to produce sweat. Hence, palpitations, dizziness, and bodily tremors occurred. I prescribed Zhen Wu Tang. After three doses, slight sweating occurred spontaneously, and the illness resolved. Zhen Wu Tang contains Fu Zi (Aconiti Lateralis Radix Praeparata) and Bai Zhu, which harmonize Kidney Qi. Once Kidney Qi moves, sweat can be produced. Focusing solely on the Taiyang meridian would only deplete blood and fluids. Zhang Zhongjing stated: 'If the Chi pulse is deficient, Ying Qi is insufficient, and sweating is contraindicated.' Thus, it is evident that weak Kidney Qi makes sweating difficult. Xu Xueshi reported: 'A neighbor’s son, aged thirty, initially presented with slight sweating, weak pulse, and aversion to wind. The physician administered Ma Huang (Ephedrae Herba), causing excessive sweating, fever, frequent palpitations, insomnia, delirium, loss of recognition, muscle twitching, and trembling. The physician then administered heart-calming medicines. I said this was an error caused by forced sweating. Zhang Zhongjing stated: 'With a faint pulse, sweating, and aversion to wind, Qing Long Tang (Blue Dragon Decoction) is contraindicated; administering it leads to muscle twitching, which is adverse. Only Zhen Wu Tang can rescue this case.' After three doses of this, supplemented with Qing Xin Zhu Ye Tang (Clear Heart Bamboo Leaf Decoction), he recovered within days. (The formula for Qing Xin Zhu Ye Tang could not be verified)."

After purgation followed by sweating, chills and trembling inevitably occur, with a fine pulse. This happens because both the interior and exterior are deficient. Patients who have lost blood (Wang Xue Jia) must not undergo sweating therapy; doing so causes chills and trembling. In Taiyang disease, if the back is scorched with fire, causing profuse sweating, and the fire-heat enters the Stomach, leading to delirium. If, after ten days, the patient experiences trembling followed by spontaneous diarrhea, this indicates the disease is resolving. (See details under "Delirium".)

A deep, tight pulse that feels hollow (Kou) upon pressure indicates that trembling followed by sweating will lead to resolution. A Kou pulse signifies deficiency, hence trembling; a floating pulse indicates exterior pathogens, hence sweating leads to resolution. (This discussion appears in Volume 1.) In Taiyang disease with pulses ceasing at both Yin and Yang positions, trembling and sweating indicate resolution. (See discussion under "Fever".) In all Chai Hu (Bupleuri Radix) patterns, if purgation fails to resolve the condition, re-administering Chai Hu Tang will cause steaming tremors, followed by fever and sweating, leading to resolution. (See discussion under "Alternating Chills and Fever".) A floating and slow pulse, with facial redness and trembling/fear, indicates resolution through sweating. Conversely, if there is fever with a slow pulse unable to produce sweat, the body will itch. (See discussion under "Facial Redness".) All conditions involving cold invasion result in Jue (cold extremities), Yu Mao (depression and vertigo), numbness, oral stiffness, inability to speak, and trembling. Invasion of the Yin aspect causes internal shivering. This is due to weak exterior Qi and unguarded interior Qi, allowing pathogens to enter the Yin.

Han Zhihe: For trembling after sweating and purgation, administer Jiu Ni Tang (Rescue Adverse Decoction); if symptoms slightly decrease, follow with Yang Rou Tang (Mutton Decoction). After another dose, trembling resolves. If interior Yin is abundant and Righteous Qi is severely deficient, presenting with mental shivering, jaw chattering, but no bodily trembling, it becomes a Cold Reversal pattern. Moxibustion is indicated, or Da Jian Zhong Tang (Great Construct the Middle Decoction) may be used. Zhang Zhongjing treated Shi Jue (Corpse Extinction) with trembling by needling Qi Men (LR14) and Ju Que (CV14).

Wu Kun: Trembling generally results from dual deficiency of Qi and Blood, where Qi fails to nourish sinews and bones, causing trembling and loss of bodily control. Great tonification of Qi and Blood is required. I once successfully used Ren Shen Yang Rong Tang (Ginseng Nourishing Qi and Blood Decoction). Another patient with bodily trembling and insomnia was cured using Shi Wei Wen Dan Tang (Ten-Ingredient Warming Gallbladder Decoction) with doubled Ginseng. The *Nei Jing* states: "Cold invading the body causes hair to stand erect, jaw chattering, and trembling without sweat." This describes exterior cold causing trembling. The classics state that some illnesses resolve through trembling followed by sweating; the pulse is floating and tight, but hollow upon pressure, indicating underlying deficiency, thus requiring trembling before sweating. It also states: When pulses at Yin and Yang positions are equal across all three positions (floating/sinking, slow/rapid), trembling and sweating precede resolution. If the pulse is floating and rapid but not hollow, and the patient is not inherently deficient, sweating occurs without trembling. If there is no trembling but mental shivering, this indicates invasion of the Yin aspect, causing internal shivering. Whenever Righteous Qi is weak and cold pathogens reside within, shivering occurs. Scholars should investigate this thoroughly.

Jia Wei Ren Shen Yang Rong Tang (Modified Ginseng Nourishing Qi and Blood Decoction): Treats excessive sweating leading to dual Qi and Blood deficiency, manifesting as muscle twitching or bodily trembling.
Ren Shen (Panax Ginseng Radix, 2.5 qian), Fu Ling (Poria, 1 qian), Gan Cao (Licorice Root, 1 qian), Chuan Xiong (Ligustici Chuanxiong Rhizoma, 1 qian), Bai Zhu (Atractodis Rhizoma, 1.5 qian), Mai Dong (Ophiopogonis Tuber, heart removed, 1.5 qian), Dang Gui Shen (Angelicae Sinensis Radix, root tip, 1.5 qian), Wu Wei Zi (Schisandrae Fructus, 15 berries), Rou Gui (Cinnamomi Cortex, 1 qian; reduce by half if heat is present), Sheng Di Huang (Rehmanniae Radix, 1.5 qian; use this if heat is present, use Shu Di Huang if no sweat), Huang Qi (Astragali Radix, 2.5 qian; use 2 qian if spontaneous sweating occurs), Sheng Jiang (Zingiberis Rhizoma Recens, 3 slices), Zao (Jujubae Fructus, 2 pieces, split). Boil in 2 zhong of water until 1 zhong remains. Strain and take warm. If Yin deficiency with ministerial fire agitation, add Zhi Mu (Anemarrhenae Rhizoma) and Huang Bai (Phellodendri Cortex), each 1 qian, fried with wine. If Yang deficiency with lower cold and faint pulse, add Shu Fu Zi (Prepared Aconite Lateralis Radix) 1 qian, double the Rou Gui. For insomnia, add Yuan Zhi (Polygalae Radix) and Suan Zao Ren (Ziziphi Spinosae Semen), each 1 qian.

Jia Wei Wen Dan Tang (Modified Warming Gallbladder Decoction): Treats deficiency vexation, bodily trembling, and insomnia.
Ren Shen (Panax Ginseng Radix, 2.5 qian), Ju Hong (Citri Reticulatae Pericarpium Rubrum, 1 qian), Fu Ling (Poria, 1 qian), Huang Lian (Coptidis Rhizoma, wine-fried, 1 qian), Chai Hu (Bupleuri Radix, soft variety, 1 qian), Dang Gui Shen (Angelicae Sinensis Radix, root tip, 1 qian), Chuan Xiong (Ligustici Chuanxiong Rhizoma, 1 qian), Bai Shao (Paeoniae Radix Alba, 1 qian), Sheng Di Huang (Rehmanniae Radix, 1 qian), Suan Zao Ren (Ziziphi Spinosae Semen, 1 qian), Ban Xia (Pinelliae Rhizoma, 0.7 qian), Gan Cao (Licorice Root, 0.5 qian), Zhu Ru (Bambusae Caulis in Taeniam, one ball), Sheng Jiang (Zingiberis Rhizoma Recens, 3 slices). Preparation and administration are the same as above.