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Cheng Wuji's Commentary: The *Neijing* states: "Yang qi, when refined, nourishes the spirit; when soft and harmonious, it moistens the sinews." Perspiration leads to the depletion of body fluids and a significant deficiency of yang qi, causing the muscles and sinews to lose their nourishment. Consequently, there is trembling and twitching of the muscles. In such cases, one should directly employ formulas that warm the meridians and benefit yang qi, such as Zhenwu Tang (True Warrior Decoction). Furthermore, after Shanghan (Cold Damage) has been treated with vomiting or purging methods, if sweating is induced again, leading to twitching and trembling of the sinews, this may eventually develop into Wei syndrome (flaccidity syndrome). Similarly, in Taiyang disease, if sweating is performed followed by purging, both the exterior and interior become deficient; if moxibustion on burning needles (Shaozhen) is then applied, causing skin twitching, this is difficult to treat. These two scenarios represent severe reversals (Ni), which are far more critical than cases involving only sweating. How can the use of sweating, vomiting, and purging methods be neglected?

In Taiyang disease, if the pulse is faint, there is spontaneous sweating, and aversion to wind, Da Qinglong Tang (Great Blue Dragon Decoction) must not be administered. If taken, it will lead to cold extremities (Jue Ni) and muscle twitching (Jin Ti Rou Yu); Zhenwu Tang (True Warrior Decoction) is appropriate. In Taiyang disease, if symptoms persist despite prior sweating, with continued fever, dizziness, and whole-body tremors as if about to fall, Zhenwu Tang (True Warrior Decoction) should be used (or Renshen Yangrong Tang (Ginseng Nourishing Qi and Blood Decoction) with doubled doses of Renshen (Ginseng Root) and Danggui (Angelica Sinensis Root)). After Shanghan has been treated with vomiting and purging, if sweating is induced again, resulting in empty irritability (Xu Fan) and a very faint pulse, and after eight or nine days, epigastric fullness (Xia Pi), hypochondriac pain, upward rushing of qi to the throat, dizziness, and twitching of the meridians occur, this may eventually develop into Wei syndrome (flaccidity syndrome). Treat with Zhenwu Tang (True Warrior Decoction) or Guizhi Ling Zhu Gancao Tang (Cinnamon Twig, Poria, Atractodes, and Licorice Decoction).

In Yangming disease: After Shanghan has been treated with vomiting and purging without resolution, constipation persists for five to ten days. In the late afternoon (You period), tidal fever (Chao Re) occurs without aversion to cold. The patient speaks alone as if seeing ghosts, picks at clothes and beds (Xun Yi Mo Chuang), feels terrified and restless, pants, has fixed gaze (Zhi Shi), and presents with a wiry pulse (Xian Mai); this indicates survival. If the pulse is choppy (Se Mai), death ensues. If there is only fever and delirium (Chan Yu), Dachengqi Tang (Major Order the Qi Decoction) is indicated. In Yangming disease, if the pulse is floating and tight, with dry throat, bitter taste, abdominal fullness and panting, fever, sweating, aversion to heat rather than cold, and heavy body, applying burning needle moxibustion will inevitably cause terror, restlessness, and insomnia. If "moving qi" manifests on the left side with continuous head sweating, the *Ren Shu* (Book of Vitality) recommends Fangfeng Baizhu Muli San (Saposhnikovia, Atractodes, and Oyster Shell Powder), followed by Jianzhong Tang (Build the Middle Decoction).

Diagnosis: After treatment with sweating, purging, vomiting, warming, or needling, if skin twitching, mental agitation, and a bluish-yellow complexion appear, the prognosis is poor (see discussion under "Pi" / Epigastric Fullness).

*Ren Shu* (Book of Vitality): After Shanghan has been treated with vomiting and purging, if sweating induces a faint pulse, epigastric fullness, hypochondriac pain, upward rushing of qi, and twitching of the sinews, this represents a severe reversal (Ni).

Wu Qian et al.'s Commentary: This condition arises because excessive sweating to attack the exterior fails to resolve the pathogenic heat, leading to depletion of blood and qi, causing the muscles and sinews to lose nourishment. Alternatively, it may not be due to this cause but rather because the patient constitutionally lacks blood, allowing pathogenic heat to contend within the blood vessels. Since fire nature is active, it causes twitching of the sinews.

I once treated a patient with Shanghan who had not undergone sweating. After seven or eight days, sinew twitching and trembling occurred, with tidal fever being particularly severe, muscle twitching, constipation, dark and scanty urination, and hard, painful tenderness upon palpation around the umbilicus. This indicated the presence of dry stool (Zao Shi). It was cured using Jiawei Dachaihu Tang (Modified Major Bupleurum Decoction) to purge the bowels. Another patient suffered from Shanghan for over ten days and had been sweated excessively three or four times. This resulted in muscle twitching, whole-body shaking, and sinew twitching. This was caused by excessive sweating leading to a dual deficiency of qi and blood. It was cured with two doses of Jiawei Renshen Yangrong Tang (Modified Ginseng Nourishing Qi and Blood Decoction). A third patient experienced empty irritability and insomnia after sweating, accompanied by muscle twitching and internal heat. This was cured using Jiawei Wendan Tang (Modified Phlegm-Resolving Decoction). When treating this condition, one must always examine whether the pattern is excess or deficiency.