bubble_chart Concept

Shiver, which is aversion to cold, manifests as an involuntary trembling of the entire body accompanied by a fear of cold. This symptom is referred to as "cold chestnut" in both the Neijing and the "Treatise on Cold Damage Diseases." Jin dynasty's Liu Wan-su Suwen Xuanji Yuanbingshi calls it "trembling." Ming dynasty's Wang Ken-tang Zabing Zhengzhi Zhunsheng refers to it as "shivering cold" in the section on cold and heat disorders. Later generations mostly refer to it as "shiver."

Mr. Qin Bo-wei, in his book "Essentials of Clinical Practice in Chinese Medicine," believes that "shivering cold" and "shiver" are different. He states, "The distinction is that shiver originates from within, while shivering cold is merely a physical movement. Shivering cold is often due to yang deficiency failing to protect the exterior, often accompanied by symptoms such as abdominal pain, diarrhea, heavy limbs, and difficulty urinating." Clinically, both conditions present with aversion to cold and trembling, making them difficult to distinguish. Qin's viewpoint is worth considering.

Both shiver and spasm involve involuntary movements of the limbs, but they are fundamentally different. Spasm involves twitching and stretching of the limbs and is not accompanied by aversion to cold, whereas shiver is often due to trembling caused by fear of cold.

bubble_chart Pattern Analysis

1. Externally Constrained by Cold Pathogen︰The clinical manifestations include aversion to cold, shivering, high fever without sweating, headache and body pain, thin white tongue coating, and floating-tight pulse. It is caused by external cold invading the exterior, pathogenic factors stagnating in the meridians, and obstruction of the striae and interstices, leading to stagnation of defense qi. Therefore, aversion to cold and shivering are accompanied by exterior cold pattern; aversion to cold and fever occur simultaneously, aversion to cold is not relieved by warmth, and is accompanied by symptoms such as no sweating, headache and body pain, thin white tongue coating, and floating-tight pulse, indicating an exterior cold pattern. Treatment should focus on releasing the exterior with pungent-warm herbs, and the prescription selected is Ephedra Decoction with modifications.
2. Deficiency of Yang with Exuberance of Yin︰It manifests as fear of cold, shivering, cold limbs that improve with warmth, bland taste in the mouth without thirst, clear urine, loose stools, a pale tongue, and a deep, faint pulse. This is due to weak yang qi or cold pathogens damaging yang, leading to the failure of yang qi to warm the body, resulting in pudendal coldness and aversion to cold accompanied by an interior cold pattern. The clinical differentiation between the two syndromes lies in: fear of cold without fever, fear of cold that improves with warmth, along with a bland taste in the mouth without thirst, clear urine, loose stools, a pale tongue texture, and a deep, thin pulse, indicating an interior cold pattern. Treatment should focus on warming yang and dispelling cold, and the recommended formula is Cold-Extremities Decoction with modifications.
3. Warring Sweat︰During the course of an {|###|}external-contraction febrile disease{|###|}, there may be a sudden onset of {|###|}aversion to cold{|###|} and shivering like foxtail millet, or even cold limbs and a sunken pulse. Shortly afterward, the whole body may break out in {|###|}profuse sweating{|###|}, after which the skin becomes cooler. {|###|}External cold and internal heat shivering{|###|}: The main clinical manifestations include {|###|}aversion to cold{|###|}, shivering, cold limbs, headache and body pain, {|###|}fever and thirst{|###|}, {|###|}dysphoria{|###|} and restlessness, scanty dark urine, dry and stagnant stools, a red tongue with yellow coating, and a floating, tight, and rapid pulse. In {|###|}external-contraction febrile disease{|###|}, {|###|}shivering and sweating{|###|} are caused by intense conflict between pathogenic factors and healthy qi. If healthy qi prevails and expels the pathogens, sweating will lead to resolution, and after {|###|}shivering and sweating{|###|}, a calm pulse and peaceful rest indicate gradual recovery. If healthy qi fails to overcome the pathogens, two scenarios may occur: 1. **Collapse of healthy qi outward**, presenting with a rapid, agitated pulse, restlessness, cold limbs, and sweating. In this case, urgent administration of {|###|}restoring yang and tonifying qi{|###|} herbs is required, such as the modified Ginseng and Aconite Decoction. 2. **Excess pathogens with relative deficiency of healthy qi**, preventing resolution in a single episode of {|###|}shivering and sweating{|###|}. Recovery may require waiting one or two days for healthy qi to gradually recover before another episode of {|###|}shivering and sweating{|###|} leads to full recovery.
4. Toxin Inward Invasion︰Local redness, swelling, heat, and pain are accompanied by aversion to cold and chills, fever with restlessness and thirst, even unconsciousness and delirious speech, scanty dark urine, severe constipation, a red tongue with yellow coating, and a surging rapid pulse. This belongs to the pattern of congestion and exuberance of fire and heat and pathogenic toxin caused by excessive internal fire-heat, meridian blockage, qi and blood stagnation, flesh decay, pathogenic heat congestion, and inward invasion of sore toxins. The common mechanism of disease in these two syndromes is excessive interior heat, as stated in Suwen.Zhizhenyao Da Lun: "All prohibitions, drum-like rigidity, and loss of mental control belong to heat." Therefore, apart from aversion to cold and chills, there are also shared clinical manifestations such as fever with restlessness and thirst, scanty dark urine, dry and accumulated stool, a red tongue with yellow coating, and a rapid pulse. However, the appropriate treatment is to clear heat, purge fire, and expel toxins. The recommended formulas are Five-Ingredient Toxin-Eliminating Decoction and Coptis Detoxification Decoction, with modifications.
5. Malaria︰First, there is yawning and lack of strength, followed by aversion to cold and shivering, aching pain in the limbs. After the chills subside, there is high fever, headache, a flushed face, and thirst with a desire to drink. Subsequently, sweating occurs, the fever subsides, and the body cools, with a wiry pulse. Malaria is caused by exposure to the malarial pathogen, where the pathogen lingers between the exterior and interior, clashing with the nutrient-defense system, resulting in a struggle between healthy qi and pathogenic qi. Clinically, it is characterized by alternating shivering and high fever, occurring at regular intervals. Generally, based on the severity of chills and fever, it is classified into ordinary malaria, warm malaria, cold malaria, and consumptive malaria. Ordinary malaria refers to the typical form of malaria, treated by harmonizing and expelling pathogens, using Minor Bupleurum Decoction supplemented with Dichroa and Sweet Wormwood. Warm malaria presents with more fever and less chills, or fever without chills, and should be treated by clearing heat and expelling pathogens, using White Tiger Decoction Plus Cinnamon Twig supplemented with Bupleurum, Dichroa, etc. Cold malaria presents with more chills and less fever, or chills without fever, and should be treated by warming and expelling pathogens with acrid-warm herbs, using Bupleurum, Cinnamon Twig and Dried Ginger Decoction with modifications. Consumptive malaria occurs in cases of prolonged illness with deficient healthy qi, and should be treated by nourishing healthy qi and harmonizing the nutrient and defensive aspects, using Fleeceflower and Ginseng Decoction with modifications.

Shivering, as a symptom, can be categorized into exterior cold, interior cold, heat deficiency, and excess. If fever follows shivering, it is often a sign of the recovery of yang qi and the abundance of healthy qi. However, if there is no fever after shivering, or if cold limbs and a faint pulse occur after shivering and sweating, it indicates yang deficiency with internal cold or the imminent collapse of yang, which must be taken seriously.

bubble_chart Documentation

1. Jingyue Quanshu．Cold-damage disease: "The battle is different from the chestnut, the battle is caused by the outside, the chestnut is caused by the inside. When the cold-damage disease is about to be relieved and sweat is about to come out, if the healthy qi is strong inside, the evil cannot compete with it, then only sweat will come out and no battle will occur. The so-called no battle means that the body is not weak. If the person is originally weak, the evil and the right compete, the slight is the vibration, the severe is the battle, the right wins the evil then the battle and sweat will relieve. Therefore, all the battles between the evil and the right outside are battles, and the battles are the ones that are healed. The battles between the evil and the right inside are chestnuts, and the chestnuts are the severe ones. It is said: Yin is hit by evil, and there must be chestnuts inside. The battle is for the healthy qi to recover, the chestnut is for the pathogenic qi to be strong, so the cold-damage disease for six or seven days, there are only chestnuts and no battles, and eventually become cold and reverse, most of them cannot be saved, this is because the healthy qi is weak, the yin pathogen is strong inside, the right cannot overcome the evil and instead the evil element is restricted, whenever this symptom is encountered, if it is not used with large supplements of warm and hot agents, and moxibustion to restore yang and other methods, how can others resist it?"
2. Yizong Bidu："The battle is the body moving, the chestnut is the jaw drumming, the evil wants to be relieved. Chestnut but no battle, yin exuberance yang deficiency, dry attached Cold-Extremities Decoction."
3. 《Chinese medicine internal medicine syndrome treatment summary．aversion to cold》："The cold evil is tied outside, and the internal heat is not transparent, or the heat is deep inside and repels yin outside, all can produce aversion to cold that cannot be relieved, or cold chestnut and vibration, or cold limbs and other symptoms."